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FOMPICE LYSE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..................... (Complete to Triplicate) Pemnit No. . � ....... <br /> ....... ,, .�. ........................ Date Issued �.; ?:7..7... <br />......................................................... This Permit Expires 1 Year From 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 ADDRfss/L ION ..: .....[.�.� :.... ..................................cENsus TRACT . ....................... <br /> Owner's Name fax�....�..n ?!d. =::. ..Phone <br /> AddressG:.'°7�/ ' ........... ...............................City ..`. _ _ .................................................... <br /> Contractor's Nome .. t' .e. ....... ............................ ......License # .. Phone .. ...J�..t <br /> Installation will serve: idence OAportment House fl Commercial❑Troller Court <br /> Motel❑Other............................................ <br /> Number of living units:............ Number of bedrooms ........Garbage Grinder ............ Lot tize ...................................... .JL <br /> Water Supply: Public System and name .............................................................._..........................................Private Q" <br /> Character of soil to a depth of 3 feet: Sand❑ Silt Q day ❑ Peat❑ Sandy Loam fl Clay Loam❑ <br /> Hardpan 0 Adobe❑ Fill Material ............If yes,type............... ............ <br /> [Piot pian, 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 f j „ Size ........................................ Liquid Depth ........................ <br /> Capacity 1 _ •r,�� � M <br /> 1' '. aterial...................... No. Compartments ..��-:-=......... <br /> Distance to nearest, Well .....,f1(................. ...Foundation ..Z4s............. Prop. Line.. .f.�..�....... <br /> LEACHING LINE ( j No. of Lines ..0................ Length of each 11 .7�.................... Total Length :�..�.�...�......... <br /> ..Depth Filter Material De .. ............................ <br /> 'D' Box ...�....... Type Filter Material _ _ p <br /> • , Distance to nearest: Well ........................ Foundation .................... Property Lina ................•..... <br /> SEEPAGE T O Depth .................... Diameter ................ Number ............................ Rock Filled Yell ❑ N o <br /> Water Table Depth .................................................Rack Size ..:............................. <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Lina ...................... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ................................ .I <br /> SepticTank (Specify Requirements) .............................. ..... ............................................................................... ........... <br /> Disposal Field (Specify Requirements) ................................................................ .................................................................. <br /> .................................................................................................................---...................................................................................... <br /> ............................................................................................................_.......---.................................................................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby codify that i have prepared this application and that the work will be done In accordance VA* San A"410 <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Nonto tvmw of Nten- <br /> sod agents signature codifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shalt not employ any person he such manner <br /> as to become subject <br /> too-�Workman's Compensation taws of California." <br /> Signed ... -` ................................................. Owner <br /> By .................. ..✓.................. .................--------....---................... Yale ...... ........................... .................................. <br /> (if other than owner) <br /> DEPARTM NT USE ONLY <br /> APPLICATION ACCEPTED BY .. .... <br /> DATE ... .._ .- <br /> BUILDING PERMIT ISSUED ..................... ........... .DATE <br /> .................................... <br /> ADDITIONAL COMMENTS ......................................... ...:........................... <br /> ....................................................................................................................................................... ............:..................................... <br /> ......... ... ................. ............................................................................... ................................................... <br /> .................................. ..... . ...... ............ . ............. ..... .......... <br /> Final Inspection by: Date .. .......... <br /> ......... ...... <br /> ........................................ ` ;7. ... <br /> EH 13 24 1-68 Nov. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />