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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) -- Permit No: .__7 . <br /> A__0 '>- This Permit Expires 1 Year From Date Issued <br /> Date Issued __1_-�-_ 3 <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/LOCATION --------------- -------------------CENSUS TRACT .---6_7 .-....._.. <br /> Owners Name -- '�- _ �-�-r-----4—jg-1-------_ _ _ -=. _- <br /> Address ''� ---- -------------------- City----- --------------------------•------ <br /> Contractor's Name _-e __ 'u%' _5�c-------License # .7__ Phone -4/9-3- <br /> Installation ill serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units------------- Number of bedrooms ------------ Grinder ------------ Lot Size ------ .,--------- <br /> Water Supply: Public System and name ----------------------------------------------------------------------------•-- ---------------------_-------Private <br /> Dd <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 'D Clay Loam <br /> Hardpan ❑ Adobe'Q Fill Material ------------ If yes,type ------------`_________---- <br /> Q <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1P <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200'feet,) W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'{ ] Size-----------------------------------.------------ Liquid Depth __----:--_--._---.-__.__. <br /> Capacity 49 ------ Type 1_= Material.L - No. Compartments _L . <br /> Distance to nearest: Well -_-__�?"- ---------------------Foundation :___1d__-_--_-_-_ Prop. Line --.,,,........... <br /> LEACHING LINE [ ] No. of Lines _____/________________ Length of each line____ ___ Total Length ----- --,�................ <br /> 'D' Box - Type Filter Material ----i_2 -----Depth Filter Material ----1-_J.f`-_............. <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ..................---._. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ,iC <br /> aX %a Y /3 Water Table Depth ------------------------------------------------Rock Size -------------------- ---------- <br /> Distance to nearest: Well __________________________________ __Foundation --_----_----___. --- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------- --------------------------------------------------- <br /> Disposal Field (Specify Requirements) -_-__--_-__. _--_--__---------------__-__._----__-_-____- <br /> -------------------- -------------------------------------------------------------------------------------------------------- -----------------------------------------=------------------------ <br /> ----------------------------------------------- ------------------------------------------- - --------------------------------------- ----------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------------------- <br /> ---------------------------------------------------------- Owner <br /> -- --- --------------------------------------------------- Title ------------------------------------------------------------------------ <br /> (If other than r) <br /> FOR DEPARTMENT USE ONLY <br /> .APPLICATION ACCEPTED BY -------- _ DATE ------ `_. �_--_---_. <br /> BUILDING PERMIT ISSUED ----------- -------------------- -------DATE .......................................... <br /> ADDITIONALCOMMENTS ------- - -- ------------------------------------------- -- -- --------------------------------------------------------------------------------------------- <br /> ------------------------- ------ --- ------ -------------------------- -- ---------- --- ---------- -------------------------------------------------------- ---------- --------------- <br /> ------------------------------------- -------- - ---------------------------- - - ----------- ---- - ------------------------------------------------------------------------- --------------------- <br /> --------- - <br /> - --------- <br /> -- ----------------------------------------------- -------- <br /> FinalInspec - --- ------ ---- --------- -------- --- -------------------------------Date ------ ---� ------ <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />