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FOR OFFICE USE. <br /> . . . ..: ` APPLICATION FOR SANITATION PERMIT <br /> .. � ............................ (Complete in Triplicate! <br /> ....... , . <br /> PermitNo. ... ... .... <br /> Date Issued .h....d °..7r <br />......................................................... This Permit Exlkres 1 fear 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 ADDRESSA ION L. _... -4...........................................CENSUS TRACT ..... ... .. <br /> Owner's Name %` :..moi .. : ................. ..Phone 46�.... <br /> Address ... �/� ..� �� ................. City .... ..... ................. ... •- <br /> Contractor's Name . ............. ..License #, ... ... Phone 27 <br /> Installation will serves (Apartment House❑ Commercial❑Troller Court ❑ <br /> Motel❑Other............................................ <br /> Number of living unlW.. ......... Number of bedrooms . 7.....Garbage Grinder ............ Lot Size . .................................... <br /> Water Supply: Public System and name .......................................................-_......._.......................................... <br /> Private� 7U <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 iNSTALLATIONa (No septic tank or_ioepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size .................................. Liquid Depth ....................... <br /> Capocity�, /'11 �fYpe .r.. ' Material...................... No. Compartments ..;2r --- <br /> ... <br /> Distance to nearest: Well f/2C. ._......:.Foundation .fly Pr L}rne <br /> ..... .a........... op. ..:........_.... <br /> a , <br /> LEACHING LINE [ ] No. of lines ..�...................... Length of, each line..1e:............... . Total Length ............... <br /> 'D' Box -:&...... Type Filter Material _a? ....Depth Filter Mafalot .`�-rte...F.............................. <br /> • , Distance to nearest: Well ........................ Foundation ........................ Property Lime ..............-. •---- <br /> SEEPAGE PIT [ [ Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ...........................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ... ...,.... ... <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................I <br /> SepticTank (Specify Requirements) .................... ................ ..............................................................._... .... ................ <br /> DisposalField (Specify Requirements) ..................................................................................................................................... <br /> ...............................•.......................................................................................................................................................................... <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 Jeaquln <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.Home ewner or Ilton- <br /> sod agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not empley any perste In such maenor <br /> as to become subject to orkma 's Compensation laws of California.*" <br /> Signed ..G - r...... .. Owner <br /> By ...Sitle ......................................................... <br /> lif other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... .... DATE .... - ............. <br /> ...... <br /> BUILDING PERMIT ISSUED ....,,.. r...... .............. .....DATE ............ .............. <br /> ADDITIONAL COMMENTS•...... -...fie `. ....................... <br /> .. s .e. . ._....... . .......... �"' . .... '................ <br /> f.n_.i:...:: ... . ...............::......................... <br /> Final Inspection by: ........ .Z.• ..... ......I...............................Date . :, ... <br /> 13 24 1-65 Rev- <br /> SAN SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />