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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..................... ... <br /> 1Complete in Triplicate} Permit No. ..7...� - ______ <br /> .... •.._._. ........ <br /> ..... This Permit Expires I Le2r From Date Issued Date Issued <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 /> q�j <br /> JOB ADDRESS/LOCATION , _,.Y!_f).___ .:_ . ... - .. f <br /> , .-I)_ �ttf. NSUS TRACT .......................... <br /> Owner's Name .--•--- �� -• _. .. ......... <br /> Address ...._._.... Phone7 � �� <br /> __ _. ._... City <br /> ••-- . <br /> Contractor's Name _----•......... ................. 1 -- . :. ._.....................License # rte` " .��... Phone , - 6f <br /> Installation will serve:~ Residence b<Apartment House Commercial ❑Troller Court Q <br /> -Motel ❑Other ............... <br /> ti <br /> Number of livin u-hits..jk.L__, <br /> Number-of bedrooms ....1/...Garbage Grinder ............ Lot Size ..../ ..lp' -�...........::.. <br /> Water Supply: Public System-and name.............. `....................................._................... __.:........Private ❑ <br /> Character of soil to a depth of 3 feet. Sdncl r Silt❑ Clay ❑ - Peat❑ Sandy Loam O� Clay Loam <br /> Hardpan Q .Adobe 0 Fill Material ......... ___ If yes.type ....................... <br /> (Plot plan, showing size of lot,. location of. system in relatiion'-t wells, build ings,'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 ae..�J�_ _�?�........................... Liquid Depth <br /> ............. <br /> Capacity �.8�0Type _._..._ Materiai.�-�_'_._ No. Compartments <br /> V <br /> r r <br /> Distance to nearest: Well --------------•----•..----•--- --., o�ndation ...... ...... Prop. Line .... .... .. <br /> i <br /> LEACHING LINE No, of Lines -------�............ Length of ch line-__._' ------- Total Length .?6 <br /> :.._.. �/ <br /> D' Box Type •Filter Material Depth Filter Material ...ke.................. <br /> Distance to nearest:'Well ....... C_.: .Foundation _.. _�.._ :....... Property Line . . <br /> Diameter ____. Number�......__y_....,_,•_... stock Filled Yes No Q <br /> Water Table Depth . Rock Size .,.y�.�.. <br /> ---•••- <br /> Distance to nearest: Well ........'=..._.....:..............Foundation Prop. Line . V. ) <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ........_.......................... <br /> ) rn <br /> Septic Tank (Specify Requirements) ............... ---. n <br /> t <br /> Disposal Field (Specify Requirements) .........-----......................... ........................ --•-- P <br /> ---------------- ---------------- .%� . ..°_� Q <br /> ----•-•------- ••-•..............------------------­­­ ........... ............ <br /> ------ <br /> (Drow 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 Workma 's Compensation laws of'California." <br /> Signed <br /> -•----------- _ Owner <br /> By ............ ---------.......... ...... Title ----------..._.••----. ... ._..:__._.....:.. ( f <br /> othe t an owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. :.. .. --- -•-------•......................•-•----•••,....... DATE ..... .. ..fes -. <br /> BUILDING PERMIT ISSUED .._• ............... ........... DATE ........................:.................. <br /> ADDITIONAL COMMENTS ..:......................... <br /> ------."I.......... ..................'..�.. <br /> ...................• -•- -•--------_ ........ ---•-•••-•-• --- <br /> � ' _.. .._._. <br /> ... --/J <br /> •---:- -�..1..�. <br /> _ ..................... ....................................... . .;---- ............... <br /> �� ---- <br /> Final Inspection b . ............ .... -----------.......--•-•--Date -•--- <br /> SAN-JOAQUIN LOCAL HEALTH DISTRICT _..---•_.... <br /> -- <br /> E. H.13 24 W68 Rev. 5M 7/72 3 .K <br />