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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. --7-7i -3 <br /> - ------------- ------------------- .. - <br /> (Complete in Triplicate) <br /> ---------- --------------------------- ------------ - <br /> . � . , Date IssuedThis Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> CENSUS TRACT ------------------- <br /> JOB ADDRESS/LOCATION'.- -4n-- ------------- ------- i <br /> ------------- <br /> Owner's Name ----- ---- = ----------------------------------- -- ----Phone ------------------------------------ <br /> - --- <br /> Address --------------- - - -- ------- ------------ City --------------------------------..------------------------ <br /> Contractor's Name .------__-License # 1? <br /> Contractor's ---"-------------------------- <br /> ----- - --- ------------ ------- <br /> Installation will serve: -Residence -Apartment House❑ Commercial ----------------------------- <br /> al : Trailer Court ',❑ - F <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 soil to a depth of 3 feet: Sand'❑ Silt O Clay ❑., Peat❑ Sandy Loam % Clay Loam ❑ <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:[-] <br /> Size-------_-/----------------------------- --- Liquid Depth -------------------------- <br /> Capacity <br /> ------------------------- <br /> Ca acitY ---------- -- - TYpe -------------------- Material---------------------- No. Compartments -------------__...... 0 <br /> y <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 ------------------------- ----------- ------ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -__---.----------.----- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ----- -.-------- Number ------ --------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------.-.------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __-----.------._--___-------------) <br /> E <br /> Septic Tank (Specify Requirements) --------------------- -------------------- •--------------------------- <br /> Disposal Field (Specify Requirements) <br /> ----------------- <br /> l -o�-r - �`� '� T 1 ` ------------- <br /> ---------------- --- <br /> - �'-�` 4 <br /> -------- -------- - <br /> --- ---- - - <br /> (Draw existing and required addition on reverse s d e) <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. Home owner or liceri- <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 --------------------- ------- -- -6 ------------------------ <br /> Owner <br /> � A- Title a � ----------------------------------------- <br /> BY <br /> ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --.-- r'-- <br /> DATE ---�~ �� – - - <br /> BUILDING PERMIT ISSUED - ------------------- ----------------- <br /> ---------------------------------------DATE ------------------ ------------------------ <br /> ADDITIONALCOMMENTS ------------- --------------------- --------------------------------------------------------- ------------- <br /> --------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- ---- ----------- ---- -- -- ------------------------------------------------------------- ---------------- - ---- <br /> ---- --- -- - <br /> Final Inspection by: -_ Date -�1�+ " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r W 0 1.'AR RPv- SM <br />