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FOR OFFICE USE: APPLICATION FOR_SANITATION PERMIT . <br /> _ <br />.........----. ............I..............._..I...._.. .. Permit No. .. <br /> (Complete in Triplicate) ' <br /> ----- This Permit Expires 1 Year From Date Issued Date Issued (0.. `.... <br /> Application is hereby made to the San 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 an existingRules and Regulations: <br /> ` S2.v ICU. O/ <br /> JOB ADDRESS/LOCATION .................( r....... .._CENSUS TRACT <br /> t . <br /> Owner's Name _CENSUS <br /> } s <br /> Address ...................... ... ............ city <br /> } <br /> Contractor's Name ._ ............License # Phone <br /> Installation will serve: Residence ❑ Ap ment House 0 Commercial [RTrailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:------------ Number of bedrooms ............Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name --•----•--•---•-------•-------------------------•--•- --._..................................------•............Private ❑ <br /> Character of sail to a depth of 3 feet: Sand C] Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ V\ <br /> Hardpan Adobe Fill Material .----------- If yes,type ............................ <br /> 3, <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 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size 15_, ----_.•----- ---------- Liquid Depth ..4;j.o............... <br /> Capacity _ T e _ "f Z. Material_C3...?7..C!✓7. No. Compartments __�__....... <br /> P Y� Type - <br /> Distance to nearest: Well _ ........................ .1.9.........__.... Prop. Line .. ------ <br /> LEACHING <br /> -__LEACHING LINE No, of Lines ------- `�-------------- Length of each line...... ........ Total Length .. .___._•___- <br /> 'D' Box ..,�.-..-. Type Filter Material ./ Depth f=ilter Material __ ...............................•_.. —• <br /> r .,.Z70&v__[_ 7�Z— <br /> Distance to nearest: Well . C ......... Foundation -.27---------------- Property Line 1 .......... <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No Q <br /> Water Table Depth --------------- ......... ......................Rock Size -------------------------------- <br /> Distance to nearest: Well.----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date _.._........................... <br /> SepticTank (Specify Requirements) ..................• .................................................................................•---__.._.............................. <br /> Disposal Field (Specify Requirements) -------------------------------------------------------- --------------- ........ <br /> •--------------------------------------------------------------------------------------------------------------•- --•-----••-----••---------•--•--•-•-•-•--_........•-•------------------ ---------- <br /> --------------------- <br /> -------------------- -----------------•----------------------------------------------- ----------- -••----•-••••-•----•------•------------••---•----- ..._...---•----...........----••--•-•- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 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 /> le- <br /> By . -- . ... . �- • -------•- Title ... --..- <br /> -_--- - ---- ---------------------------------........ <br /> (if other than owner <br /> FO DEP TME USE NL <br /> APPLICATION ACCEPTED BY ----•----... . •- --.-_ • .......L'" ...... ~• DATE ..�.1 .... <br /> BUILDING PERMIT ISSUED ....__._._. DATE .................... <br /> ADDITIONAL COMMENTS ..................................................................................... <br /> -..._... ------------------------•-----------.-....-•------•-•-------•_....._-------•--....._......---..._........... <br /> -••- <br /> ....................... ............. ......... <br /> ... . ........ ........ .... ...... ..................................................... ...Pc/.7-!/............. <br /> Final Inspection b Date ._-.-. _. -.-. <br /> p Y ---•--•...................•--....__. <br /> SAN JOA Ul LOCAL HEALTH DISTRICT <br /> i E. H.13 241-'b8 Rev. 5M __. _ _ _ - 7/72 M <br />