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FOR OFF! USE: ........... APPLICATION FOR SANITATION PERMIT ` <br /> Permit No. <br /> :.........�...... . �(�..................... IComplete in Triplicate) <br /> � ....................� <br /> ......................................................... This Permit Expires t 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/LCCATIOISI CC�4. : ,A.-,=............................................CENSUS TRACT .......................... <br /> Owner's Name .......... - --_-_Xt...­qj.4 ...........................................................Phone 7` . ..'° a..�..L..... <br /> Address ...... 5 77 Z- - ...:... .........City .................................. <br /> ................. <br /> ... <br /> . .. ..... <br /> 6 �� ..Contractor's Name -.-_.i - :. ._.�: ��•�'�t!J.......................:License llt�.�'"��..�.�..... Phone .�.---- .---: <br /> Installation will serve: Residence [•Apartment House❑ Commercial❑Tra(ler Court 0 <br /> Motel❑Other............................................ / <br /> Number of living units ... ...... Number of bedrooms ...y.Garboge Grinder ..... Lot Size ............... <br /> Water Supply: Public System and name ..--..•........................_......--•...... .... ..................Private ❑ <br /> Character of soil to a depth of 3 feet- Sand❑ Silt❑ Clay 0 Peak[] Sandy-Loom Q Clay Loam <br /> Hardpan❑ AdobetA Fill Matorlat ......:.....If yes,type............... ............ <br /> www�e.w��walww�wwwr�w�w�i i <br /> (Piot plan, showing size of lot, location of system In relation to wells, buildings, oft. must be placed on reverse side.{ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 204 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size............................................... Liquid Depth .......................... <br /> Capacity --------------•----• Type -----•---------- Material...................... No. Compartments ...................... <br /> Distance--ta=v*west: Wall-___......................Foupdatipn ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines .-._-_-.._-------_... Length of eachline............................ Total Length ............................ <br /> D' Box Type Filter Material .......Depth Filter Material —I <br /> Distance to nearest; Well ........................ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ j Depth --------------_-.- Diameter ................ Number ............................ Rock Filled Yes ❑ No 0 <br /> Water Table Q th ..........................................,...-Rock Size ................................ <br /> Distance to nearest: Well ...•................::.::..............Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ....... .......................................�...... . ......................._..,................._........... P <br /> Disposal Field (Specify Requirements) --•-_-. Q ............................ ........... <br /> 1.�".x25....... ....�: <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 Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Meow O)sMd. Monte mmw or Ilcen- <br /> sed agents signature certifies the following: <br /> "I 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 - ----------------------------•----------- title .-:.. �.�f...-. <br /> r <br /> (I a e than owner) <br /> F0Jt-WPAJtTVdNT USE ONLY <br /> APPLICATION ACCEPTED B ..._ .._ .......... DATE .- ....: ...`... - <br /> BUILDING PERMIT ISSUED ...<-.-_....... ..............ADDITIONAL COMMENTS DATE ._:.. <br /> --- - - - ----- -------- -- --- - --- _----. <br /> ---------------_- -------- <br /> --- ---- --- <br /> ............J ----------- <br /> Final Inspection by: ......... ... ....................................... ......-•-----... Date .-. rte' ...'.. .----- - -)----......... <br /> EH 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />