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FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT Z <br /> ....-r ........... ..... :.. ... it NQ. . ------ <br /> .. <br /> �.. (Complete in Triplicate). '� ;'"` <br /> - 71 <br /> S� <br /> ............................................. <br /> .......................................... .Date Issued T�7 <br /> : <br /> ................. . <br /> ........................ <br /> This Permit Expires I Year From Date Issued <br /> Application Is hereby made to the San Joa uin Local Health District for a permit to constrctndjinstall the work herein <br /> described. This application is made in compliance ith County Ordinance No. 549 and existing R 0leslond Regulations- i <br /> JOB ADDRESS/LOCATI N ...CENSUS TRACT .......................... <br /> Owner's NameQ . ...:....:. ..... <br /> ... .. . . <br /> Phone --.. ---•---•---- ......... <br /> tae .. . <br /> Addressc � .....City ------- <br /> Address <br /> Contractor's Name ......� a License ..:.._.._: <br /> -- Phone• <br /> Installation will serve:-T----ow.—Residence Apartment House J:1 Commercial t]Troiler Court fl <br /> r <br /> = Motel []Other...: ---- .-............ <br /> � T <br /> Num of living units .... Number of bar s ...Gar ge Grinder Lot Size - Q <br /> - <br /> WaterSupply. Public S stem and name .. ... . .........- --__ <br /> :...:.... ..........:... ..... <br /> ..._...Private . . <br /> Y <br /> Chara ter of soil to a depth of 3 fest; Sand n Silt 0 Cloy {Peat❑ Sandy Loam 0 Clay Loam❑ t i11 <br /> l Hardpan 0 Adobe t3 Fill Moterlal ............if yes,type <br /> f <br /> (Plot plan, showing size of lot, location of system In relation to wwells, b liu dings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepa. e'pit permitted if public sewer is available Liquid2Q0 feet,( <br /> • S <br /> i .. ... <br /> Size:...._..... ...........�M i Depth ...--•••......... .... <br /> PACKAGE TREATMENT [ � SEPTIC TANK ...............•.--- <br /> i -Capacity •---- --'}TY Material-------- ------ --- No. Compartments •• :_...... <br /> -•- <br /> Disto ice.to nearest: Well .Foundation ......................Prop. Line ...................... <br /> LEACHING LINE { ] No. of lines ........ ................ Length. of each line.--...........•-•- Total Length <br /> 'D' Box ............ Type Filter Materia9 .....-•---.....-.•..Depth Filter Material .................. <br /> _J. <br /> Distance to nearest: Well ... Foundation Property Line !.......... ............ <br /> SEEPAGE PIT [ 1 Depth ---.-..----- <br /> ' Diameter Rock Filled Yes No Q <br /> ---•----•--•---- Number ..............:............. ❑ <br /> I Water Table Depth ...................flock Size ......... .............. ._.. <br /> Distance to nearest: Well ..........foundation .................... Prop. Line ....:......----------- <br /> .......----- <br /> Sanitation Permit�# -••-•--•--=- ---- Date .............. .................... <br /> k REPAIR/ADDITION(Prev. .....-•-----....�._ <br /> Septic Tank {Specify Requirements} ...:..------ - - .:.... ._ ....•............................ . _.... <br /> :. <br /> Disposal Field (Specify Requirements( ..-- �y�-- - . ..... . <br /> --------------------------•--------------------------- <br /> ----- ..... --•••........-- . :1 .... _.... ----•--- <br /> (Draw existing and required on reverse side) <br /> I hereby certify that 1 have prepared this application and -that addiilon tho-work-will-be-done-In-accordance-with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the 'San Joaquin Local Health.IJisiritt. Ham* owner or lice* <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 --------------------------- -------------------------..-•..............•........................ <br /> Owner <br /> �- If other t an owner)� <br /> +� DE R M. E ONLY <br /> APPLICATION ACCEPTED BY -­ ---- . DAT E.._.,---......... ....... _ <br /> BUILDING PERMIT ISSUED ----------------------- .....DATE -- ---- --•-••---------- ........ <br /> ADDITIONALCOMMENTS -------•-------•• ............... . ....---•--...--••-- -------•--•--•----- :--------....-•-------.._..._------•._...--.-- <br /> / <br /> . .. .................. <br /> -------------------------- ---------- ...... ........ - <br /> ••--••...................... .. ........ ------- . ._..... - - ••.._...... .. ... <br /> Final Inspection by: ...Date -. <br /> Eli 13 24 1-68 Rev. 5M SAN JOAdUIN LOCAL HEALTH DISTRICT �I 3N <br /> I <br />