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t Y FOR OFFICE USE. APPLICATION FOR SANITATION PERM11T <br /> '....... .......................•---•----........... Permit No. `... <br /> (Complete in Triplicate) <br /> '4 Date Issued .............. ..... <br /> '-•.................................. This Permit Expires 3,Year From Date Issued <br /> Application is hereby made to the Son 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 //(00.,- y ���" CEN5t�5 TRACT ............ <br /> Owner's Name ..........firer f..._.. ................ ......... .....Phone ....... <br /> ....... <br /> Address ._........ Q3.y'.. IYa <br /> .-. -4D�s- ? .......­1 City •; E4.�C� ^� <br /> ............................... <br /> Contractor's Name -----• :. __..�a- `�`�.&8`.. - ` ,-- "�- ..........-.....License # `5 .3 3....... Phone'..tic,66.:56.10...... <br /> Installation will serve: Residence [3 Apartment House f] Commercial f❑Trailer Court ',❑ <br /> Motel ❑Other ...................... 5 <br /> Number of living units:...... Number of bedrooms .......Garbage Grinder ............ Lot Size ............... <br /> Water Supply: Public System and name ----------------------------------------......-•---------.............................---......................Private P9 <br /> Character of soil to a depth of 3 feet: Sand a Silt C] t Clay❑ . Peat❑ Sandy Loam ❑ Clay Loam10 <br /> Hardpan.Q, _. AdobFill Material-•---....... If yes,type .•-.---_-.:.. _ .......... <br /> (Plot plan, showing size of lot, location of1system in relation to wells, buildings, etc must,be placed on reverse side.} <br /> NEW INSTALLATION- (No septic tank or seepage pity permitted if public•sewer" voilable within 200 feet,) <br /> PACKAGE TREATMENT E SEPTIC TANK Sloe:_f..?s��ti...........:..Y-.--..._.._... Liquid Depth <br /> -.1` •.--•----....... <br /> Capacity .f7 '? . Q. Type i .......•.... Material._ .E' _, No Compartments .................., <br /> t '"` otindatianl f'� 2.s 6 <br /> Distance to nearest: Well ...:--. � �`?...:........... t?__•----•_-.. Prop. Line •-•---._............. O <br /> LEACHING LINE ( No. of Lines __3............... Length of each line'.....1-00................ Total Length .4 .............. <br /> D' Box ... Type Filter Material ._ e.�'�.......Depth Filter Material .:. ..-------•..................•. <br /> � G <br /> Distance to nearest: Well ...._. ........... Found6tion\..a-_---------------- Property Line 4?-. <br /> SEEPAGE PIT [ } Depth _...I______________ Diameter ------ --------- Nu4d ....V_.................. Rock Filled Yes ❑ No Q <br /> Water Table Depth !Rock S"ize ' <br /> t <br /> Distance to nearest: Well ........ _.::r?... -•- --•--....rFoundation .................... Prop, Line ....................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........._.........................!------- Date ... <br /> Septic Tank (Specify Requirements) .............. ' <br /> Disposal Field (Specify Requirements) t ..a..•------...................................................---------- <br /> ______________________________________________________ _ ____________________________________________________a......._._.______ ._.._........._.___.______.-______..........+..._.__................- <br /> I , <br /> ---------------........... ------------•------------• ......................•-• -- -•-------- -------------------------------- ............. -----------I........------- <br /> .....:... <br /> (Draw existing and required addition on reverse side) <br /> Thereby—certify that`I have preiiaredthii,applitati4wand'that the-,work will be done:in-accordance.,with San Joaquin <br /> County Ordinances,, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen. <br /> sed agents signature certifies the following. I I <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 <br /> as to becomes biect fiWorkman's Cam ensation laws of California." <br /> Signed ---- -----4 ... .A.. "a .........:....- Awner <br /> 13y ................... ......1�- -.. .. . . ... . . ..........._......................_.., Title ....AV_—$-.................................... ............... <br /> . <br /> Y (If other than owner) <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... . ---•--- ----- ----------.................................................... DATE .. 7. --------- :...... <br /> BUILDING PERMIT ISSUED .............".... ...... <br /> - ._...._ . .DATE ........................................... <br /> ADDITIONALCOMMENTS ................................................. •-----..........._....-••.--•••-•• ..................---•...........:.:..................... <br /> .............................................................. .............................................. .............---...................... ............�...................--•--- <br /> ------------------••--••-•--•-•-•-- <br /> A <br /> Final Inspection by, -----•--•-•- Date . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .. 7 R 94 7179. <br />