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Ft3R OFFICE USE: <br /> �° t�© �t V APP1.tCA'iON FOR SAMrt'ATION PERM <br /> ._---------- <br /> Permit No. <br /> ..71` -..... .-. <br /> ................. . . 0 (completeln Trip"tatel <br /> . 1/ Dots Issued �. 7 7.f� <br /> ............ <br /> ..................................................... This Permit Expires 1 Yearfrom Daselssued <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 ADDRESSACICATICMV <br /> Owner's Name �.. I. .•.......................................................... �. <br /> ... .... •.. S TRACT one <br /> r! <br /> AddressO city 7 • a <br /> Contractor's Name r ................... ..L <br /> Installation will serve: Residence j&Apartment House❑ Commercial❑Trailer Court ❑ <br /> Motel Q Other............................................ <br /> Number of living units:........---- Number of bedr9pms ,, .'. . --Garbage Grinder : ' ?.... Lot Size . .......... <br /> Water Supply: Public System and name ......_sem '.......c'rs: `' r .:........................................................Private Q <br /> Character of soil to a depth of 3 feet: Sand b Silt❑ 'Clay ❑ Peat❑ Sandy loam ❑ Clay Loam ❑ <br /> Hardpan Q Adobeig• Fill Material ............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be plated on reverse side.} <br /> NEW :INSTALLATIONNo i <br /> l septic tank or seepage pit permitted N public sewer. is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size................................................ Uquid Depth .......................... <br /> Capacity -••-•---•-••-----•-• Tyle ----••---•---------- Material...................... No. Compartments ...................... <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 ............................ Rack Filled Yes ❑ No <br /> Water Table Depth ................................................Rock Size ................................ <br /> Distance to nearest: Well ............................:,::p—Foundation .................... Prop. Line ...................... <br /> RFPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> SepticTank (Specify Requirements[ ................................................................................r.......................................................... <br /> Disposal Field {Specify Requirements) ...... - ... r! 1 -----... . '1 ......... .b/` ..... <br /> - <br /> . !'- ..................... --•-•--._.---••• .................................................... ..............................................._...........:.••-•-- <br /> •----••---•-•--------------------••--•--•--•---•---••----••-- -------------------------------------------- ._............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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,DisMd. Nance owner or Nam <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit Is Issued, I shalt not employ any;pen in such manner <br /> as to become suble�to Workman's.Compensation laws of California.,, <br /> signed __ a <br /> }'�✓f ;. ., a -------------------- Owner <br /> e ... � r t ; ---------- ------ - ----------- _.. title ........... .. __...:-----. --------- ----- --------- <br /> {if other tha3�c�a�� --.. <br /> R 4EPARRAWT USE ONLY <br /> APPLICATION ACCEPTED BY - .. - ...----- DATE ... 7 <br /> $UiLDING PERMIT ISSUED _... - ............. ............. ••••... ----- DATE ....- <br /> ADDiTIONAL COMMENTS ...................... <br /> ...................... ------------------- --- • •- ,----------- •-••.. ....... •• •-,---..... ..........,............. ........................... .......... ...... <br /> •------•------•-•------------------ -- <br /> Final Inspection by: ..-•-----••_... --- -••_.._ ........... ........... <br /> IEH <br /> 13 2!t 1-613 • SAN JOAQUIN LOCAL HEALTH DISTRICT 8`7]13M <br />