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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ~ 3 —• ::. :....... IK. Permit No: <br /> . <br /> {Complete in Triplicate( <br /> •••••••••-•-------...•.•.•............................... This Permit Expires 1 Year From Date issued <br /> Date Issued .�.�� 3.. <br /> Application is hereby made to the San Jrooquin-,Local- a t,�h District for a permit to construct-and--ins 3l.fj e1wo�ic�-herein <br /> described. This application.is made In compliance�i it�` , tokt�,Ordlnonce No. 549 and existing Rules and RegWations: <br /> JOB ADDRESS/LOCATION <br /> _ '� ... . ..CENSUS TRACT <br /> Owner's Name .... � '�. . ... .---`.....................-- ._.............. I ...... Phone .................................... <br /> Address ._.. .... t.... ., � ................... - <br /> - ---••-.a ........... .................._..._................ <br /> Contractor's Name ....../ ... .....................................License #0 /'%Rr3��" .. Phone <br /> Installation will serve: ResidenceApartment House'❑ Commerc€a€ :❑Trailer Court ] <br /> Motel ❑Other ............................................ <br /> Number of living units_ Number of bedrooms , ...-.G,arrb-age Grinder . Lot Size OgrQ_ ..� ...... <br /> Water Supply: Public System and name � f�rj___• ,� ,��.,�---� %/,�� !.............................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ `"Peat❑ Sandy Loam 0 Cloy 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 INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.t ] Size............... .....•--- ............. Liquid Depth .......................... <br /> 1 Capacity ................. °. Type .................... Material...................... No. Compartments ...................:.: - <br /> C Distance to nearest` l4ell ....... <br /> i cl # € <br /> • ..........--•-----------•-•-•-----t.Foun a ion .................•---- Prop. Line . <br /> No. of Lines ................._ ;_�. <br /> Length of each line....---..................... Total length <br /> LEACHING LIN3 <br /> D' Baxp .....--_.... Type Filter Naterial Depth Filter Material <br /> .................. <br /> Distance to nearest: Well .............. Founddtion ...._............_..... Property Line ......................... <br /> SEEPAGE PIT ] Depth ............... Diameter ._............. Numb(r ._...___ ................... Rock Filled Yes No ❑ <br /> i <br /> Water Table Depth ..............................................'.Rock Size <br /> I Distance to nearest: Well ---------------_ ... Foundation -----............... Prop, Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# ...................... .................... Date .... ............... <br /> Septic Tank (Specify Requirements) ...........s o .Disal Field (Specify Requirements] `&.4. <br /> , , ..._a ...,a , - -- :_.......fs �n ... <br /> --- ......... ............ .. ........ <br /> ...----... I <br /> ......-• ............................... .... <br /> (Draw existing and required addition on reverse side) '' <br /> I hereby certify�fhat I have,ipr;j a;red this application and that the work will be done In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulation's of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: - eE W <br /> "I certify that in the performance of the work far which this-permit is issued, I shall not empioy any person in such manner <br /> as to become subject to Workman's'Comp nsation laws of-California." i <br /> Signed ............... -- Owners <br /> BY ----•---... _` ... • Title ..�� ........:Y� :..........................::-. w. . <br /> (If er than owner --�''— --"- _ <br /> "DTMENT_USE ONLY <br /> APPLICATION ACCEPTED BY <br /> .......... ........ ............................. DATE ---•--- � <br /> .].7� <br />� BUILDING PERMIT ISSUED -'--'-•--' <br /> ADDITIONAL COMMENTS .. ...... .. ................ ATE ..._... <br /> --..._.. .-----...!. ... .�. .................... ........................................-.............I.....---.....-- .........._.... ._ <br /> ................................. . . . .. ............................................................................. <br /> Final Inspection by: .. - •: - ....•_..._Date ...•.... <br /> N JOAQUIN LOCAL' HEALTH DISTRICT <br /> fi' E. H.13 241-'68 R v. 5M 7/72 3-M <br />