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FCR OFFICE USE: <br /> APPLICATION FOR`SANITATION PERMIT. <br /> Permit.,No. _..... <br /> (Complete in Triplicate) ►'. , <br /> rw =........_.... <br /> - - �----.... r:. ,� ...-...'(�`. -. i Date Issued .�..d~..�/-_.. <br /> +l This Permit Expires 1 Year.From Dats Issued <br /> -- --- ------- .... . <br /> * I Health Districts for' a', perrrYi.to constructFand install the work herein <br /> Application is hereby made to the San Joaquin Local H <br /> described_ This a lication is made in'complia a with County Ordinance No��;549 and existing R�leslu{i d Regulations: <br /> pp _ "1 <br /> } ��f fir, I CENSUS! TRAC : ..�- -.:..... <br /> JOB ADDRESS/LOCAT N _- t � -14 <br /> •/? - a,;j-r _ ' t 1 <br /> Phone ---------------------------------- <br /> - <br /> Owner's Name <br /> • --------.-••-- <br /> • Address -- •-'--­- ---- ---==.......-------- <br /> ...... City S/-`1� f ,1��,�_...... ._ -• - --..__...._.._ <br /> ri <br /> �� °� ::�Phone �j� c 21�lei <br /> t . <br /> Contractor's Name _.._.._ /`} Commerc al5e#r��Z:. G�-_; <br /> r. <br /> Installation Will. serve: Residenci�!1�portment House'l ,O t <br /> Motel ❑Other - = = ................ I <br /> Number of living units:._...`'.._ Number of bedrooti��n....Garbage Grinder .....0-. Lot Size�C?L? <br /> Water Supply: Public System and names..- . ---------------------------------------------- <br /> Cloy [] <br /> --..----------•-----...:�...Priva <br /> Private,. <br /> Character of soil to a depth of 3.feet:�f' Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> f ►...: r.....--- i <br /> ' oHardpaan ❑ -� Adobe Fill Material - ------ If yes,type •--- (/ <br /> (Plot plan, showing size of'lotlocation of system in relation to wells, buildings, etc. mu�st�beplaced on reverse side.} <br /> I l� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available with`n 200 feet,] <br /> PACKAGE TREATMENT [ 7 . SEPTIC TANK'[ ] Size.-.-.-------_-------------------•i • :_F-Liquid Depth _-.-_-- ------------------ )� <br /> Capacity ..--.Type ..:................. Material -- o. Compartments ..... . ...... V <br /> + t <br /> �.�. Distance to nearest: Well .... ............ ......•Foundation. - ----- -- Prop. line --------------- <br /> LEACHING LINE [(_]._No...of.Lines_ ,.................... Length of each line-------- __.---._._-- ------ Total Length ,._..... ...--- ....... <br /> ii <br /> 'D' Box .-......--.. Type Filter Material ....................Depth Filter Material ............:......................:........ <br /> >f . <br /> --- .____ Foundation Property Line" '1 <br /> Distance to nearest: Well ............. -----••'----------"'-""" <br /> SEEPAGE PIT [ ] Depth _.._ Diameter ................ Number ................... ........ Rock FilledlVes ❑ No <br /> ..-•------- it �J` <br /> Water Table Depth -- ------------------ Rock Size ----------------"-..--.-..------ ` �� <br /> Distance to nearest: Well ............................•--.."-•-....•Foundation ----------.........• Prop.• Line _1'`:............ <br /> f; _ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----_------- ................"------------- Date ._.__•_.__"-..--_-------.- <br /> Septic Tank (Specify Requirements S <br /> ..... .... ....•-•-•"---r...... <br /> ... <br /> ......................: ` ••••-•- "' r <br /> Disposal Field (Specify Requirements) <br /> �d <br /> . ......... ........_ •----------------------------------------......... -•-------- -----.... . <br /> (Draw existing and required addition on reverse side) r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Lavks, and Rules and Regulations of the Son Joaquin Local Health District.`Hdine ownef or licen- <br /> of <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any poken in sdeh manner <br /> as to become subject to Workman's Compensation laws of California:' ✓, <br /> Signed ----_--------------------- ----- - --------- <br /> =- •--.---`- --:.... Owner <br /> .-•-•-----_------------ ---•- .............•.. <br /> • L��f"[f y Imo. �i <br /> (If other t a owner) <br /> PARTMENT-USE ONLY <br /> K. DATE -----/:7 .......-._..... <br /> APPLICATION ACCEPTED BY ..---- ...................................... .................. <br /> BUILDING PERMIT ISSUED -------- --------•• ..............DATE ---.............................. <br /> ADDITIONAL COMMENTS ------- <br /> ...............................................................................-------------------------------------------------- <br /> ....... . . . .. . <br /> . <br /> Final Ins ection b ...............................Date _.�— •-•-'-1- �• , <br /> / S OAQUIN LOCAL HEALTH DISTRICT vi <br /> E. H. 9 1-'68 Rev. 5M <br />