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-FOR OFFICE USE APPLICATION FOR SANITATION PERMIT <br /> a Permit <br /> .......... (Complete In Triplicate) <br /> ........---• flare meed 1../• .. t - - <br /> l This Permit Expires I Year From Date Issued <br /> i <br /> Applin is hereby made to the San Joaquin local"Health District for-a-permit•.to construed and Install the work hereto <br /> ca o <br /> described. This appiication,is�-made in compliance with County Ordinance No: 5�l9 and existing Rules and Regulatlons: <br /> .� <br /> JOB ADDRESS/LOCATION. - •z ..�.-- .. . ..........CENSUS. TRACT .. �j ......- <br /> Owner's Name ...�/ u� 1�._ .. ....: . ......................:z>..* .......Phone'- <br /> Address - ..--------••-••`.AJ/ ..........................................................City ... r. G?�.......... .. .............................. a <br /> Contractor's Nam® .. .[�.. .;/ � - ........__. • :.. . . -.License_ . . . ;�Phonsl ... <br /> InstaNation will serves Residence(jqApartment H6uao❑'Commerclal-13TrallerCOurt- <br /> " Motel[3 Olher.. _.................................... f <br /> Number of living antra:_-- .�.... Number of bedrooms .....Garbage Grinder . Lot Size........................................... <br /> Water Supply Public System and name ------- ------•--••-•---••--.— .............. . _..:'...Private® 4 <br /> .... ` <br /> Character of soil to a depth of 3 feet% Sand Silt❑ Clay ❑ Ppm❑ y;�d+`,C `' CIOloa"�' Q <br /> ...�.... :: ..... . ..... <br /> Lardp in obe❑ fill Materidl IPyes;type •!=- <br /> 'Plot pian, showing size of lot, location of system in relation to wells, building, �_'etemust be placed on kreverse side.),*..1 <br /> aW . <br /> NEW INSTALLATIONr INo septic tank or seepage git_perinitted if public seM%avoilable_withln 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] \+ ` Size............................................. <br /> Liquid Depth .................. f <br /> ` Capacity .................... Typo .......�. ....... Material. ....�......... No._Compartments ..... .......... ... <br /> i Distance 'to nearest: Well ....................::::::: 'cfoundation . :~..: 'f P op. Ine .................... <br /> EACHING LINE [ ] No. of Lines ...................... . Length of each line........................... <br /> . Total`Length :...:.............. <br /> -- Ty0e Filter'-Mdteiial":::::._.-'::"::":-Depth Filter-Mafieflal_,. .777=.......................... <br /> Distance to nearests Well .:....I................. foundation ........................ Property khrie <br /> SEEPAGE�lT [ � Depth ----.�.............. Diameter ................ Number ............................. Rock Filled Yes ❑ No- � <br /> WaterTable Depth ................................................Rock Size ........................... <br /> Distance to nearest: Well ................. ......................Foundation .................... Prop. Lino ..........-.. ... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# ............................................ Dote ---............................ •1 f <br /> ;. <br /> �Septic Tank ISpecify,Requirements? -....: <br /> ... ... �' , ........-- --... ........... l ...... <br /> . <br /> ©isoosal fi Ia cify Re uirementslI - � �. . . �...... <br /> . �. ... ..... ................ <br /> ............q,-:, <br /> '� .._ - .........._.._........._.._...... ......... ................................ ....................................... . . .................._ ..................... ... <br /> {Draw,existing and required addition on reverse sidel M <br /> I hereby certify that I have prepared thip application and that the work will be done In aceerdanas`w111r 3ait JeaRuin <br /> County Ordinances, State Laws, pnd Rules and Regulations of the San Joaquin Local Health District. Hone oweteir er Itcen- <br /> sed agents signature certifies the following: i_ -mar <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In such manner <br /> as to become sable to kma ' Compensation laws of California." <br /> ..... . OwnerS gnet� ... ..--- <br /> r <br /> I <br /> By .... :..................................: ..................................... ............ Title ...................................................... . <br /> lif other than owner( <br /> ,7 Folf DEPARTMENT USE ONLY <br /> APPLICATION,.ACCt:P_TEIa BY1 . ... ........ ................ DATE:1 �; . . <br /> BUILDING PERMIT ISSUED w .�., .: =-........:z` .`: �. ........ :DATE-..: ................ <br /> ADf31TIONAI COMMENTS .. ,.: ............................................` f-'-- - .. ........................... ......................... <br /> ........ .........•------_.. ........................................:....-----............ ..._ .............................. <br /> -•....................•--- .... ...... ----.. .............----........................-- • .......---.--..............-............................................ <br /> ......... . .... .......... .................•--._. Date .. <br /> --- <br /> final Inspection by: ---••-••....................................... <br /> to ..�. :. - -- <br /> EH 13 2h 1-btl 1 5m/ SAN JOAQUIN LOCAL HEALTH DISTRICT BI711 31 <br />