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FOR OFFICE USE: )� ; <br /> APPLICATION FOR SANITATION PERMIT y �/ <br />.................................._.._...._..--•-- Permit No. ..�.'�.. <br /> (Complete in Triplicate) <br />........ .................... <br /> ........................-•.• This Permit Expires I Year From Date Issued Date issued /........_........ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and tinstah 1he work herein <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> ,• <br /> JOB ADDRESS/LOCATION -J <br /> ���..- - --L. .... ..........•. CENSUS_TRACT - <br /> _ f <br /> Owner's Name ... . 'l!.........! "�7 �..... - ....... . .. . --•-- .........:.....................Phone .................................... I <br /> Address •---------- ....... ...... ,. <br /> ....................t ...��2-=f-�--._.-----,-. .................----•--•-----•------•... City _ . ..... .... <br /> _.._-..._. _ fi d License # L�. .7 Phone <br /> Contractor's Name •-_ .. � <br /> installation will serve: Residence ZrApartment House 0 Commercial ❑Troller Court <br /> Motel b Other ------------- _-- .................. _ .. . <br /> Number of living units:............ Number of bedrooms .. ..Garbage Grinder ............ Lot Size ... C _ 70.......... <br /> Water Supply: Public System and name .................................................--.........--...... ...........................................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand .Silt❑ Clay' ❑ Peat❑ Sandy Loam Q Clay loam <br /> Hardpan ❑ Adobe ❑ Fill Material ........_._ If yes,type ............................ <br /> (Plot plan, showing size of lot, location ofsystem 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 240 feet,J <br /> PACKAGE TREATMENT ( ] SEPTIC TANK ] Size.......................•--•-•----__.••-------.._. liquid Depth .......................... <br /> Capacity .................... Type __... ........... Material,_.................... No. Compartments ............ <br /> t <br /> Distance to nearest: Well ...................................`Foundation ..................I... Prop. Line ................. <br /> LEACHING LINT: ( ] No. of Linesg <br /> Length of each. <br /> r• line-_y_______________s_ Total.-Length......... .............. <br /> � r <br /> 'D' Box ........._'Type Filter Material Depth Filter Material <br /> Distance to nearest: Well Foundation . Property Line <br /> AYES� .rt. <br /> Y - _ .. <br /> [ 1 p •`�..�•. . ��' -•... •-------•---•--• Number <br /> --R •---��................. Rock'!Filled �:Yes "�.,.Na..[j <br /> -..•_ ... •----- <br /> -SE; PisCB�E� Depth /P -meter...---•• i+lumiserock Size..----•----••.............. <br /> Water Table Depth <br /> Distance to nearest: Well ........................................Foundation' ..................... Prop.- Line ._--_.___-_ ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _..._.... .....:....................... Date ..) <br /> Septic Tank (Specify Requirements) ___......L c�raA ..__ .--,�.. �� -.----- --- <br /> Disposal Field (Specify Requirements) .......................... ---- ------- --------------------_-------•-_---• ------ <br /> .................................................... ----•--...-----•-•-•---•--..........------------•----- - ............................ ............................. <br /> (Draw existing and required addition on reverse side) <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 Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licen- <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 become subject to Workman's Compensation laws of California." <br /> Signed - ---- ---•----• — -------------------------- ----------------- Owner <br /> 0' <br /> By ......... �t yet--� --- --------•------•---- Title -----•.. ...................:............ _...__........ <br /> f th r tho r <br /> FOR EPA MENT USE ONLY <br /> APPLICATION ACCEPTED BY ....... <br /> /y... ..... - --•---•---•............... DATE .._.._..I_` . ------ <br /> BUILDINGPERMIT ISSUED --------- - ----------•-----------------•- ..... . .........../_............... .........DATE --•-••------.... .......................... <br /> ADDITIONAL COMMENT'S ..................:.." •-....._..---....... -- - ----------------•----•- •••--• ..................................................... <br /> _______________ ................. ------ ---•-------:-- <br /> -. <br /> pectian by: .................. <br /> .......... ... .__ ----•---.--,Date _.... .�...r�-� <br /> SAN JOAQUIN LOCAL H LTH DISTRICT <br /> l <br /> 3 24 •tee n,.. ear 772 3 M <br />