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FOR OFFICE USE- <br /> APPLICATION APPLICATION FOR SANITATION PERMIT G 3 <br /> ............. .........................•------_..._ ...... <br /> (Complete in Triplicate} Permit No. ..............-�..... <br /> ......... ..................I....._..._......_......... , <br /> - Date Issued <br /> _...--_.- ...............,............... This Permit Expires i Year From Date Issued s i <br /> Application is hereby made to the Sori',Jouquin Locbl Health District for a permit to construct and instoOihe work herein <br /> described. This application is made in complipnce with.County Ordinance No. 549 and existing Rules and Regulations.- <br /> JOB <br /> egulations:JOB ADDRESS/LOCATIONr_......_...��` ��/r. ....—CENSUS TRACT ................I......... <br /> Owner's Name --------- s................................................-.__:_....Phone.................. <br /> .................... <br /> Address ._..... T�A�P .................. ......... ............. ....... .......... City ....-..--------- ........................................................ <br /> 114 <br /> Installation <br /> =Z .. <br /> Contractor's Name .......,��/..f?_�...�Qd��c�'_____�-�--..............•--------License # ca�1f�.,�-,�.-. Phone l. ..---•- <br /> Installation will serve: Residence Apartment House❑ Commercial '❑Trailer Court <br /> .' Motel ❑ Other --------:~i..... <br /> - <br /> Number of living units ... Number of bedrooms -__!� O.Garbnge Grinder ,-0-_- Lot Size . ff :................ <br /> Water Supply: Public System_and_name.,-,-,....... °. __..:: .._....Private, <br /> Character of soil to a depth of 3 feet: Sand Silt❑ �Clay ❑ Pet❑ bandy Loam C] Clay Loam <br /> I.i <br /> Hardpan ❑ Adobe ❑ Fill Material .......... If yes,type ................ <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 with in.200.-feet,)__ ` <br /> PACKAGE TREATMENT ( ] SEPTIC TANK J Size.............: /..--.__..._.__....--.._--.--. Liquid Depth ..................:....... <br /> ' .... Material---..------ No. Compartments <br /> Capacity -------------------- Type .....----••--•-- ...................... <br /> Distance to nearest: Well ............ ------------Foundation .. Prop, line <br /> LEACHING LINE [ ] No. of Lines -----------__i___..... Length of'each line___________________ Total Length ...___. ..................... <br /> 'D' Box ----- Type Filter Material ......................Depth Filter Material ..................................:... <br /> Distance to nearest: Well ............... Foundation-0:.:.....___.__._.._.._.. Property 'kine ..................-•---- <br /> i U✓ NA <br /> SEEPAGE PIT Depth Diameter Number ....... ..... ......... Rock Filled' Yes ❑ No !D <br /> Water Table Depth <br /> ' ••-•--------------------------------------------Rock Size ................................ <br /> Distance to nearest: Well ........-•..............................Foundation ----------- Prop. Line ....................... <br /> REPAIR/ADDITION-(Prov. Sanitation Permit# ............................... ��. Dates.•......................----"} <br /> Septic Tank (Specify Requirements) ---------------------------------- I <br /> _..._.......- --•--- _................. <br /> Disposal Field (Specify Reauireme .ts) __.�r�e .._ i---• -• • --•--eve -�_-- - •-_--�..... .-----_--- <br /> _......;> ' ` - ::: f r X-)4 -------------------------------- --- <br /> l '. <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 <br /> .--.----------- -- ------------ Owner <br /> Title <br /> %BY <br /> than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... . ------------------------------------------------------------- DATE ......... ... ................... <br /> i BUILDING PERMIT ISSUED .............---............................. .......................................DATE ..........•-... ........................ <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------_...........,..._.._..__....------..._.....---------...-•---•--.a.....:__._........_._...... <br /> ------------------------------------------------ --------------------------------------------•----------•------------------------------- - <br /> ....................................................... :_:................................ / .... .... <br /> ._.-.... <br /> ----------- ------ ................. . . X .............. 4 ---�:....... -_--- ----- - ...................................................... <br /> Final Inspection by: .__.._ ., .. a �. ....................... Date _ .... <br /> ar ..... <br />! SAN JOAQUIN LOCAL HEALTH DISTRICT dt�) <br /> 13 24 7/723 ,1 <br /> S E. H. 1•'68 Rev. 5M - <br />