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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �3 <br />. ._ _.- .......................... �� Permit No. <br /> . ..�:......... <br /> (Complete in Triplicate) <br /> .. ................................... <br /> .........................•..7. This Permit Expires 1 Year 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 /> JOB ADDRESS/LOCATIO ,�1�. -... .. ... .. ., .- ......04........... ......................CENSUS TRACT .......................... <br /> Owner's Name .. .. . ..... .................... .I.....--•...... ......Phone .................................... <br /> Address ..----__----_----- <br /> 2- - 7 L1��-'� ....... City ......��C/ ....... <br /> ... �..� .Contractor's Name ......- . .. ... ... ...... -----•- .........License #lt��.� ..3-... Phone .............._............... <br /> Installation will serve: Residence 2fAportment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ............................................ <br /> Number of living units:..... ..... Number of bedrooms ...--•-.....Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ....---•-•---------------•---.....................-----...--•-......._.........................................Private 1! <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ 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 see ge pit permitted if Oublic sewer is available within 200 feet,) <br /> 11 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size. ..e1 .--.. !� ................ Liquid Depth ... <br /> • <br /> Capacity 4_Ie.0..... Type . 4J�w?... Material..--_ - -. - No. Compartments ...;.?..............._' <br /> Distance to nearest: Well .............. ...�o...............Foundation ......a.......... Prop. Line ...5.............. .0 <br /> i <br /> LEACHING LINE [1/ No. of Lines .........../........... Length of each line............ r.... Total Length .....`l E'................. J <br /> P� <br /> 'D' Box =..----- Type Filter Material ...... /Z.....Depth Filter Material ......j 1.................................. <br /> Distance to nearest: Well .......�c........... Foundation ......../.r_........... Property Line ... '.................. M <br /> Depth .---.J.L'...... Number .-..-...../...... ...... .. Rock Filled Yes [�' No iQ . <br /> Water Table Depth ...............��:...........................Rock Size ..l. . . . X......._......... <br /> i <br /> Distance to nearest: Well ........................................Foundat .....1-.0......... Prop. Line ..�5............... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......---•-•• .............................. D te ..................................) <br /> SepticTank (Specify Requirements) ...................-......................................................................---......------.........••••...._................. <br /> Disposal Field (Specify Requirements) ..... ? <br /> - ................................. <br /> •-----------------------•--------------- .................... --------•--------•----........----.....-----••-----------------....---.........--•-••----•---........----.............-••••-•....... <br /> 0 <br /> .................................................. ........................................................._............................................................................................ <br /> (Draw 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 San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Mom* owner or licen- <br /> sed agents signature certifies the following: <br /> "1 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 /> By •... . ........................•----..........La.lYx�y!. :111 - Title . -c1>-........................................... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY ...........&log-�............................................................................... DATE .....7 ....... ...�................ <br /> BUILDING PERMIT ISSUED ........................................:.... ._........ ......... ............................. <br /> • DATE .. .... .. . <br /> ADDITIONAL COMMENTS ...7r 29 7-$e....... �..Ge�r��� :use-..............�r1 t..:........................... <br /> ....•••-••---•••-••-•••-•-.....•••..........................................................•-••-•--•-•-...................•••-•-............•••••....-•-.............._............_..................... <br /> .....------••.......................•----.......---............-:..:......... ............----•-...........---............................. <br /> ...........................'..... <br /> Final Inspection by: �. ..�...................................•--•-•---......... ........ <br /> ..................Date _0A <br /> SAN <br /> ..?. ............... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241-'68 Rev. 5M 7/72 3 <br />