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FOR OFFICE USE: APPUCATHM FOR SANITATION <br /> gPERNUT <br /> .. Permit No. .7S <br />,.......� rM (Complete In Triplicate,) pate <br />........................................................ This Perrrdt Expires 1 Year From 0010 Issued . <br /> Application Is hereby made to the San Joaquin local Health District for a permit to conshVd and install the work heroin <br /> described. This application Is made M compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .......................... <br /> -......................... .........CENSUS TRACT .............. .......... <br /> Owner's Name .............l............ .......r .. ............... ... .......... ........ . ..Phone,./.-023k........... <br /> Address ................... .. .... .. ......... ......................City .. .. . ............................................ <br /> Contractor's Name .............. . .. ... '........................License#zwS. -.-15 *11... Phone .'r b.--2�a...... <br /> installation will serve: Residence('*Apwtrnent House f j Commorclol❑Trailer Court <br /> . <br /> Number of living units:.......... Number of bedrooms ...2::�--Garbage Grinder ............ Lot Size ...... -1 .....�'f." <br /> Water Supply: Public Systom and name ........................................................_......._..........................................Private <br /> Character of soil to a depth of 3 feek._ Sand D Slit❑ Clay Q Peat❑ , Sandy loam❑ day Loan❑ <br /> Hardpan❑ Adobe(� Fill Mcterial ............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to welts, buildings, etc. must be placed on revers side.) <br /> NEW INSTALLATION: (No septic tank at seepage pit permitted if public sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size................................................ Liquid Depth ........................... <br /> Capacity .................... Type .................MatedcL...................... No. Compartments .................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line............... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of eachline............................ Total Length ........................ <br /> 'D' Box ............ Type Filter Material ....................Depth Fiber Material .......................................... <br /> Distance to nearest: Well ...... Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ j Depth Diameter ................ Number ............................ Rack Filled Yet ❑ No <br /> Water Table Depth ............ ................................Rock Size ................................ <br /> Distance to nearest:Well ........................................Foundation .................... Prop. Line ..................... <br /> REPAIR/ADDITION[Prov. Sanitation P # . ..................: .. . pate .......... ...�.................. <br /> ) <br /> Septic Tank [Specify Requirements) Q :'-:�....r. :: "r .1� 7.. . :. . �.. ........................ <br /> Disposal Field (Specify Requirements) ...: �.:� •�f ..: �� r ................................ <br /> .......................................................................................................................................................................................................... <br /> .................---..........-•----.............................................................---........_............................................................................................ <br /> (Draw existing and required addition on reverse") <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance with San J"Vin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Mesitlr District. Nem* owner or {teem <br /> sed agents signature certifies*wrfellewing: - <br /> "I certify that in the performance of the work for which this permit Is Issued, I shall net employ any person In such manner <br /> as to become subject to Workman's Compensation laws of California <br /> Signed ..... .... ............................................ Owner . <br /> By .......... ... . * .<.....4 ! ......................................... title ..... ' ............ ........................ .......... <br /> (f o than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... .. ...... . .... ....... DATE ..... .. ..y?l-� .:7�............. <br /> BUILDING PERMIT ISSUED ......DATE .....• •..••••••.. .....................•• <br /> ................. ................................................................................ <br /> ADDITIONAL COMMENTS .................:.....•..................... <br /> ....................................................................................................................................................................:..................................... <br /> .................................................................................................................................................................. ............................ <br /> .............. <br /> final Inspection by: '� <br /> ................... ...... ........................... ......................... .Date . .� ............... <br /> EH 13 21, 1-60 liov. 5H SAN JOAQUiN LOCAL HEALTH DISTRICT 8/7b <br /> I�� <br />