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aFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit Na. ..7:�r.AJ <br /> .................................................._. (Complete in Tripliiate) r <br /> ..........................•---.........._...... F <br /> . Date Issued .................... <br /> _..._......_............."_.._.........._._......__-_.. This Permit Expires 1 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 /> CENSUS TRACT <br /> JOB ADDRE55/LOCATI N�... ...:............... _..�_ ................_.::...... <br /> Owner's Name .. •.............. ...... .. _. _. .... ... .. ........._...............,............. ........Phone ----• ............... <br /> r <br /> Address <br /> - ••-----. �_��-- -------------- --•-- --- ----•---. ._.�.....--- - - � ity ... _..... <br /> Contractor's Name ----... .. ••-------- .. --=----.License # ..._....__... .... Phone ......................... <br /> Installation will serve: Residence eApartment House❑ Commercial ❑Trailer Court <br /> Motel ❑ Other .......................:. <br /> Number of living units:._'.... Number of bedrooms ::..Garbage:.Grinder ............ Lot Size .. ............. .... ................... <br /> Water Supply: Public System and name -_--------•--- ----- � -----.-•---_----....................- ..._...Private i� <br /> Character of soil to a depth of 3 feet: Sand b .Silt❑ Clpy ❑ .Peat❑ Sandy Loam ❑ Clay Loam E�� <br /> Hardpan ❑ Adobe 0 Fill Mpferiol _........... If yes,type ............................ <br /> (Plotal n, showing size of lot, location of.. system in relation .to well s,..buildings, etc. must be placed on reverse side.) f <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) VJV <br /> V'• <br /> PACKAGE 'TREATMENT [ ] SEPTIC TANK-t��_ Size. ,l --- .x--�. ............. Liquid Depth ...7....__•----......... ?f <br /> M <br /> Capacity- 1,247.0 <br /> _ .. Type Material... ..._. No. Compartments an................ <br /> Distance to nearest: Well ��et' .. .. Foundation L_Q ___. Prop. tine ..__ .......... <br /> •-- <br /> LEACHING LINE [� No. of Lines ....... ......Length of eacWline.--------ate . ..__ 'total Length _J.(.4F.Ar....... <br /> r <br /> 'D' Box -- . ....: .. Depth Filter Material f. <br /> . Type Filter Material �-�'�`----•- .__. ..-•...........................•- <br /> Distance to nearest: Well _.__. :... Foundation AK/1. .......... Property Line :. ...:...:.: <br /> SEEPAGE PIT [P1 Depth Diameter 3A_`-___. Number _.:__. .....:....•._... Rock Filled Yes k No 0 � <br /> /,�-- n <br /> Water Table Depth •••---•---•- <br /> ' <br /> Rock Size ... 1. <br /> . <br /> Distance to nearest: Well .......... ...Foudation -__--f.C� .. Prop. Line ....._J_.... <br /> .......... . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .__•..............................•--•- ---- Dot e...................................-__) <br /> 0 . <br /> SepticTank (Specify'Requirements) -•----------------------- ..............................--•---.....................•....................._ _.._..._......_ ............ <br /> Disposal Field (Specify Requirements) .............. =` ------------._......-•----------..._.._._ ------------- <br /> --------------------------- --------------•-••-----•---------.......................................... --------.....................-----•--------------:_...........•-•---------........................ <br /> i�- <br /> I ................................•-........--_. --.------------.,.----------------._..,.-._....-----------------.....,...-------------------•--•---•-•-------------------........-----.--• <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. Home owner or Been <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 Workman's Compensation laws of California:" <br /> Signed ................................................- Owner <br /> __. Title <br /> BY ..............................:.........•---- . .................... <br /> (If other than owner) <br /> FOR DEPARTMENT,USE ONLY <br /> f APPLICATION ACCEPTED BY ..--- ...........-................................................................ DATE ....../.I.`.........I ............. <br /> BUILDINGPERMIT ISSUED ..........................:.. --------------...._....---..-•-•-• .....---..........__•_:.------.DATE .......................................... <br /> ADDITIONALCOMMENTS ....................•--------------•---••-•------•--••-•-•-•-•----....:.............------..........._....... ....................._,__........................ <br /> _ <br /> ._._._... ......:................:................... <br /> ......................... ..........:... ---•-• ........_....................... <br /> .. <br /> 'h <br /> ...........:.................... ............... . -----•-----....--•-••. <br /> - <br /> Final inspection by. ...................... ............Imo" 4 Date ...1 -.�..�_ .___..... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT" r <br /> E. H. 13 24 1-'68 Rev. 5M - -- - <br />