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FOR OFFICE USE: • <br /> E APPLICATION FOR SANITATION PERMIT <br /> +................... Permit No. 77.... .777... <br /> I {Complete in Triplicate) <br /> ;......... ._..... ........... I <br /> -_ .................... This Permit Expires 1 Year From bate Issued 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 mad6 in Jcompliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> I JOB ADDRESS/LOCATIO G�rr,�....'NJ . _ «/. :-...._._...CENSUS TRACT -------•--•-------- ...... <br /> Owners Nome ...... _.....'`'' _. � .................................... . ---......Phone ................................. <br /> Address --. � <br /> 1.". ...-.-..-. _..._ .... .. City . .............. <br /> Contractor's Name .. ...... --�-�1..... .... ._..._ __.license # .AU73 R.?.7 Phone ................. ............ <br /> Installation will serve: Residence ❑Apartment Nouse•❑ Commercial ❑Trailer Court 0 <br /> Motel p Other ... <br /> I Number of living units:..=.... Number of bedrooms - -. ---Garbage Grinder . .--- lot Size ............................................ <br /> Water Supply: Public System and name ----------------•------........•_......... .......... --------------- ------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 1?11/ Clay Loam 0 <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 within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ J Size------.•---------...........:..... .....•- -.-- Liquid Depth ....._...--- ................ <br /> Capacity ..t Type -------------------- Material.... .......... No. Compartments ......................IE <br /> Distance to nearest: Well . .....----..•.---..................Foundation ............:......... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines _ . . Length of each line ......... ................ Total Length --------- .................. <br /> 'D' Box -..,.._ .... Type Filter Material ....................Depth Filter Material --..-.............I....................... <br /> . <br /> Distance to nearest: Well ------------------------ Foundation ......_...... --- Property Line ........................ <br /> I SEEPAGE PIT [ 1 Depth _. Diameter ................ Number ---- Rock Filled Yes No <br /> Water Table Depth ...Rock Size ........ ................-...... <br /> Distance to nearest: Well ..--- -------- ..._ ......Foundation Prop. Line ------ <br /> REPAIR/AD DITION <br /> -__._REPAIR/ADDITION(Prev. Son itotionlPermit# --------------------------------------• --.. Date ....... .------•..,----•------) C <br /> t _ G <br /> Septic Tank (Specify Requirements) ........ ...... ..r---- - - -----•---�...---- -------....-•-•-• - -...-- ----....--,-...-._....----. .._.-... - ---:._.._.._....... A <br /> Disposal Field (Specify Requirerrme ------ " ... <br /> • ........................•-. --- • -- <br /> �(Dra'w 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 Sari 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 arkman'sCompensation laws of California." <br /> Signed .:.. ........... ...... ------ i Owner <br /> BY ...: .... .. <br /> _: Title . .... . ..... raj <br /> _. <br /> (If other�t an owner) <br /> FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY ....-.-- �.�_....... DATE _... .... ..-. ............ .. <br /> ---..._ . <br /> BUILDING PERMIT ISSUED ---_-._ ..... <br /> - DATE ...........................•-.............. <br /> ADDITIONAL COMMENTS ---------------------------------------------- ... ------- <br /> [ ..................•...................................... ----------.------.----------------------•-------------------------------------------........................... ................._........... <br /> .................................................... ......-..__.... - ---------•.---------- : •-•..................... ..........._ <br /> FinalInspection by: ......................`_ ....................... ----• .......--.............. _...----•-•----...._..-----.........Date .. .. ]fG-..._,........... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> '.. E 14. 13 24 t.-Aa itp.._ s 7/723 �K <br />