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r <br /> FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. , <br />........................................... <br /> a� <br /> This Permit Expires 1 Year From Date Issued Date Issued ... r........ <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 � ._ _ .............. <br /> JOB ADDRESS/LOCATION ..... �...-._p � !1f+�•�-:. - CENSUS TRACT k <br /> Owner's;Name' �"r ----- �.._.. ,'�� Phone. ... w... ......Y� <br /> Address'. `�,Z r• _ . .. <br /> . <br /> fu .:. . ...Y. _. -•------- Cary ..._ '- . ........ .............. . . <br /> Contractor's Ntarne .. _.__.. �/_. .. ..._::__.License # .....Phone: -'-....---------- ..... -- <br /> Installation will serve: Residencepartment House omrr�ercial'(]Truiler Court <br /> Motel her .. M <br /> Number of living units-... Number of. bedrooms .Garbage Grinder Lot,Size_._-•--,---.-------- ...... ........... <br /> Water Supply: Public System and name .....-.......... <br /> ---•- --::_. - :,_-:_;..­Private <br /> Character of soil to a depth of 3 feet: Sand❑ ilt❑ Clay ❑ Pear❑ Sandy Loam 0 Clay Loom 0 <br /> F P. � Ij .. ., <br /> Hardpan Adobe Fill Material , If yes, pe <br /> ................. <br /> (Plot.•p!an, showing size.--of lot,.-Location ,of, system ,in relation.to wells,.buildings,' etc ..must..be placed .on<-reverseside:} <br /> NIEWINSTA4ATION: (No se' tic tank o.,r.,s.ee a e� pit permitted i- <br /> .pujlc. sewer is. 'available within 200 1 <br /> feet,) <br /> f <br /> PACKAGE TREATMENT [} SEPTIC TANK'. -f-]- –�� +-'-�----Size.—,'­-.-..: <br /> -- • Liquid,Depth . ...... ............ <br /> m Capacity --- Type -- _ . Material No. Compartments' ................. <br /> �i <br /> D'istagce to nearest: Well .: --------------- -Foundation - _.._:_---- Prop. Line :. <br /> LEACHING LINE ( ] No. of lines Length of earn Ione Total Length -. <br /> "D Box":_;: - Type Filter'Materitil ----_. D`epfFi`Filter'Material : .......... ... ... ...... <br /> Distance to nearest. WeIF : Foundation t. . _.. :.`: Property Lme <br /> Y <br /> "Filled No-c'PIT --.Depth: •Diameter Number. ;.. Rokm <br /> Water.;.Table.Depth.. :----- ..... _._Rock 5ize,., , <br /> " Di'stan'ce to nearest: Well Foundation Prop line ___ <br /> 4-PAIR/ADDlilON Prev. Sonitbtion Permit#-- _-_. _.....: b <br /> ( - -- Date - --------- - - • <br /> Septic Tank (Specify Requirements) _ _ - <br /> _ <br /> :. � .. <br /> r <br /> Disposal > field (Specify i2equirements) ...._- `5-` h ..---:-� ---- .;.__ ...•. .S''X/Z- r.`_ 'r <br /> ......._•................................... ....._._----- --'-------.._.......-------- --------` .__ _-__ ..-- ...... .._. --__ ...... _._._._.__..- t <br /> (Draw existing and required odd.ition on reverse side) <br /> I hereby certify that I. have prepared this application and:that the work will bedonee in accordancewith Son Joaquin <br /> County Ordinances, State Law's, and Rules and Regulations of the San Joagvin local Health District: Hoe'ewner or lits+i- <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 <br /> as to became subject to Workman's Compeniation laws of California." <br /> Signed F <br /> g - ----- Owner <br /> By - .. . .-...If other than .. .. ...... Title . ..-. .............. ... ... ......... <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ---- .... ... ... ......._. DATE .........y,-/7­/­15--:-3-3 <br /> PERMIT ISSUED'............................... :-..DATE - ................... <br /> ADDITIONAL COMMENTS ....... ------------------------------ <br /> ---------- ..:...... .. .-._..:._.... <br /> ........... <br /> .-._... _ .�--� <br /> Final Inspection by: .. = :..- Date ----- .�f�_:. �5............... <br /> ' r <br /> _ w r SAN-JOAQUIN LOCAL HEALTH DISTRICT v _. <br /> E. H.1.3 24 1-'68 Rev. 5M 7172324 <br />