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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> C� <br /> •' Permit No:6( Y6�-_l.. <br /> (Complete in Triplicate) <br /> - Date Issued --/-- 7=-�''- <br /> --------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with Co t Ordinance No. 549 and existing Rules and <br /> Regulations-9� N��I ,X <br /> p� G b q - -- CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATION W--------------- --1---- --�----���-------L�� -- �� ---- <br /> Owner's Name / I fr e.r&-------13 f ------------------------------------------------ -------------------Phone------------------------------------ <br /> -. Cit /2l-� <br /> Address _ _ _ ��i-Y✓---------------------------------------------------- <br /> License <br /> ---- - ------------------ -----------------••-- <br /> �. • ��; 9.--fid/ <br /> Contractor's Name -- -- ----- -- C ------------------ --*---.License <br /> Installation will serve: Residence Apartment Housef ommercial ❑Trailer Court I❑ / <br /> Motel ❑Other --- <br /> Number <br /> -Number of living units------------- Number of bedrooms ------------Garba ge Grinder ------------ Lot Size --------------------------------------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe '❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <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 [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ---------------------.----- (^ . <br /> Capacity --- --------------- Type -------------------- Material---------------------- No. Compartments -----------=----=----- 1 <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------:-.-..------ <br /> LEACHING LINE [ ] No. of Lines -- I------------------- Length of each line--------I- 0_-.---_.- Total Length ,1 a0--------------•--- ti�.r <br /> 'D' Box .-� ' -- Type Filter Material -AIT........Depth Filter Material ----- .9"--- <br /> Distance to nearest: Well ------------------------ Foundation ------ ------------- Property Line -------__------__-_----- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----__-_.------------- ----- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ------------- ------------------ <br /> Distance to nearest-.,Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------4-------------------------- -- ------- Date ----_-----------------------------I <br /> Septic Tank (Specify Requirements) ---------------------------- ---------------------------------------------------------------- - - --------------------------------- <br /> Disposal <br /> ------------------------Disposal Field (Specify Requirements) , --------/--'&--------- --..----C Ice, e-l1-/5 tP-J/--------0(/ai*0641 <br /> �.a 1 li fig° y <br /> --------------- ------ - ----�-jam-- ------------��-r�-----_-L' --- <br /> L�S . t ° -'. ------ --------------------------------------------------- <br /> (Dra exist' g 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"Son Joaquin Local Health District. Home 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, 1 shall not employ any person in such manner <br /> as to become subject to W man's Compensation laws of California." <br /> Signed --- _ - �_ Owner <br /> - - ---- <br /> By ------------ -- - Title --------------------------------------------- ------ ---- ------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED, BY -------------------------------------------------- DATE ------------------- <br /> BUILDING PERMIT ISSUED --- ------------------------------------------------------------------------------------------------------DATE <br /> ADDITIONAL COMMENTS ---- -----------=------------§----- ---- ----------------------------------- <br /> ----------- <br /> --------- - ------ <br /> -'--_-- ____ -f --------------------------- <br /> ---------- ------------------------------- - __ - ____---- '� ------ __-__.------ ___.__-- ---- __ ---__ <br /> �� �-iG <br /> ------- - --- -------------- ----------- - _----- ---------- --- --------------------------- <br />' -------------------------------- �.r'- - ------- ---------- --------------- --------- --------------------- <br /> Final Inspection by: -------- -----Date - :& ---------------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v. <br /> E. H. 9 1-'6B Rev. 5M <br />