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FOR OFFICE USE: o <br /> 3! APPLICATION FOR SANITATION PERMIT <br /> lComp ete In Triplicate) <br /> Permit No. .... S... ... <br /> •--------................•-----•-••......-•-•............ <br /> ......................................................... This Permit Expires 1 Year from Date Issued <br /> Date Issued .................... <br /> Application is hereby made to the San Joaquin Local Health District for a,permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No._549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION__'6:'1R.y-?...,/.F._1... /4. / r--.�.{................CENSUS TRACT ................:......... <br /> Owner's Name .. �ls''"� p �1 �... .�r�P��....•...................................:,....:............:.........Phone ..........................--._------ <br /> f <br /> Addressd �.............................. ,:.._.f.... City .., '�1l.........................._................. <br /> Contractor's Name .... il............. .....License <br /> Installation will serve: Residence XApartment House fl'Commercial OTra€ler Court r t <br /> Motel❑Other.................�­// <br /> Number of living,units:-............ Number of bedrooms .___ ___.Garkiage Grinder .IVP.. Lot Size . ........... <br /> Water Supply: Public System and name ........................................................._---..-............................... ...........Private®. <br /> Character of soil to_a depth.of.3.feet: Sand E] Silt o Clay jJ Peat❑ Sandy Loam I[]. Clay loam <br /> Hardpan 0 Adobe fl Fill°Mater€al ..._ ....... If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I SEPTIC TANK ] size.... :'..........:......................... Liquid Depth ..................... <br /> Capacity --- --------------- Type ..____......_ ...... Material--------_-----_...._ No. Compartments .___....._... ....... <br /> Y Distance to nearest: Well ..._.•...... _.Foundation ..... Prop. Line . <br /> LEACHING LINE { ] No. of Lines ........................ Length of-each --------- Total Total Length <br /> _-.-.... <br /> 00 <br /> 'D' Box ............ Type Filter Material ._.-__•.............Depth .Filter Material ..._..•.... ............................ <br /> Distance to nearest: Well ........................ Foundation ....._.......I. ` <br /> --•_-_. Property tine ........................rn <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _...---•-- ..... Number ...... ---------------•----- Rock Fisted Yes No (]' <br /> Y <br /> Water Toble,Depth <br /> ........... ....................................Rock Size ............................. <br /> i <br /> Distance to nearest: Well Foundation Prop. Line <br /> ._ .-....._. •.... ............�, <br /> REPAIR/ADDITION(Prev. Sanitation Permit# `........................................... Date -------- ................ <br /> Septic Tank (Specify Requirements[ ..............____............................ <br /> - .....:: ............................. ., ................. <br /> Disposal Field (Specify Requirements) ----- ��-•--,�!� � � •-------__--- <br /> -------------------------.'----------------------------- .....---------•----•-- ----•---.'- - .... . . • <br /> ....................._- . ----....._............................. ........ <br /> (Draw existing and required addifion on reverse side) <br /> l Thereby certify that 1 have prepared this application and that tha work will be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Locat Health:District. Home owner or Itcen- <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work for which this permit is issued, I shall not employ any person In such manner j <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------•--- ----- -- --- _ . _ .. --••-•------------------------...._.---.._.- Owner <br /> BY ...................• ........-- <br /> -------- Title -. -------------- <br /> of er than owner} <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...- .- <br /> -- - ----- ----- ------- ••-•-- -...----------...---------.-..-...-..--•-----.. DATE -.L�..L.�.:.7- ....-....---=== <br /> BUILDING PERMIT ISSUED ......... .-•....... ............................DATE .- ._..-..........._............ ........ I <br /> ADDITIONAL COMMENTS - <br /> --------------• ......_..... <br /> ---- <br /> ---- ----------------•--- ------`--- -•- <br /> •, <br /> ----------------- --` - - - --- ---'--•...................-•---------.--.--_----------- ...................... <br /> Final Ins ection b Date <br /> P Y . .. . ............ ................ ....... .............. <br /> ELI 13 2h 1-613 Rev". ! <br /> SAN JOAQ IN LOCAL HEALTH DISTRICT 8/7h. 3M <br />