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FOR OFFICE USE- <br /> APPLICATIONL FOR SANITATION PERMIT <br /> _. . . . . . ICornplete in.Triplicates. _ m .W . ...Permit No. ��.. <br /> ............................................ Date Issued .. . ...---... <br /> ..............-- --• This Permit Expires 1 Year Front Date Issued <br /> . .. <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 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ... ... CENSUS TRACT ------------- <br /> ��� <br /> Owner's Name <br /> -..... -......................--•...... - ............ -------------Phone ........ ----•-------------------- <br /> Address -- ----------------- <br /> 7 ---------- 8� �-r`" -E �� City L�"r <br /> .._ - <br /> Contrador's Name ----_- . ••>---- --.7 -'7 .._ _.._....License .�� - "--: Phone ---------•-------------------- <br /> Installation will serve: Residence[Apartment House f-] Commercial❑Trailer Court ❑ <br /> Motel 0 Other-------------------------------------------- <br /> Number of living units:----:-�_-._ Number of bedrooms --_- .--Garbage Grinder ---.-------- Lot Size . _ a_-- � .� --- <br /> ••- <br /> Water Supply: Public System and name ................. <br /> -----------------------•----.....---------------.__........----._..._------._._............._Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt d Cl y [J Peat❑ Sandy Loam 0 Clay Loam 0 <br /> Hardpan a Adobe V?Fill M6terial ------------ If yes,type............... ............ <br /> 4 <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 availoble�within 200 feet,) <br /> tPACKAGE TREATMENT [ ] SEPTIC TANK; ] Size------------------------------------------------ Liquid Depth .....................11 <br /> Capacity ------ ,•----------- Type -----------•-------- Material---------------------- No. Compartments ----------------� <br /> Distance to nearest: Well .Foundation ...................... Prop. Line <br /> LEACHING LINE ( j No. of Lines ...................... Length of each line-------.•----•............... Total Length ....---................ <br /> Vt <br /> 'Q' Box ............ Type Filter Material ....................Depth Filter .Material ............................................ <br /> .T <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ....................... . <br /> SEEPAGE PIT { j Depth ----.._--- --------- Diameter .-- --- Number 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 ........... ...._.....) l� <br /> Septic Tank (Specify Requirements) --------------------- ............................................. =---•-------------------------- ------•..._......-- ........... <br /> Disposal Field,.(5pecify Requirements) ...... t.,----tb - •---- <br /> ------------------------ ---------------------------------------------------------•--..........----•----...........:................................._.......--•---------•--. <br /> E (Draw existin '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 Joaquln Local Heal&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 /> Alc <br /> 1 13y ....................... _..... �3__.._.--• Title _. .. ------ -. .......-._ .. ..•.-- <br /> .............. <br /> (if other than owner! <br /> FOIR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY,;C;.- 13 ---- DATE .�` -21......... ............. <br /> BUILDING PERMIT ISSUED <br /> ------------------------------------ --------- ------------------- ---... <br /> • ---------------------DATE _...---------------_.-.-...-_..._....:..__. <br /> ADDITIONAL COMMENTS --•.................. ...... <br /> ----------- ----------- ---�-•--• <br /> - ......_.....------•-----.------.._..__...................-•-•-- <br /> ------------ --•-•-----._._....------......._............. -•---•------......-•--.------------. --------------- ..........-......................................... <br /> I <br /> --------------------------- ---------------------- •---- .. .-----...----------....._------------.... ------- ...................... --------------_ .. <br /> ------ ----------------------------------------- <br /> `-.....---....................................... .. <br /> I Final inspection by: . --------------------•--•-- ....._...........------- Date ..t`' -?. / ._._. .. ... •--•---- <br /> EH 13 2L 1--68 Heir.5H <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />