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FOR OFFICE USE: APPLICATION FOR•SANITATION PERMIT / <br /> Permit No. �t✓ne�-�? <br /> . ................................................. {Complete In Triplicate) <br /> p Date Issued Z .� <br />_ This Permlt Expires t Your-from 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 Coun rdinance No. 549 and existing Rules and Regulations- <br /> .......... <br /> egulations: l <br /> c�Nsus TRACT . <br /> JOB ADDRESS/L IOIrI .._4._. .. .............. .........---- .. ............ <br /> Owner's Na .. . . _ ._ _ .----- •- -- - <br /> Address ._ --------------••-------- ........... City ............................ ---••----- . <br /> Contractor's Name .................License # ......................... Phone .......-,............... <br /> ---•-----------_-- ------• -.....---•.... ..................... <br /> Installation will serve: Residence[yAportment House t] Commercial o railer Court ❑ <br /> a a k <br /> fi Motel ❑Other .........................•g--••........ -- , <br /> Garbage Grinder .._.._..... Lot Size r <br /> Number of living units:.--_�_:_--._ Number of be r ms __----.--- "" <br /> Water Supply. Public System and name ........................................Private { <br /> Character of soil to a depth of 3 feet: Sand'/Silt❑ Clay ❑ • Peat❑ Sandy Loam fl Clay Loam ❑ <br /> FIII Material yes,type Hardpan❑ Adobe❑ .......... If es a ............... ............ <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 I ) SEPTIC TANK I Size...........................:.... .............. Liquid depth .: . . :. <br /> 1 i ___ No. Com artments� •..�........-� <br /> Capacity 42-00---- TYp <br /> Mated p I <br /> A /,� <br /> Distance.-I nearest: Well L ----r•••••-••••• --Foundation Prop. Line ...... ................ <br /> t n <br /> f Total LengthI I .. <br /> LEACHING LINT~ No'° of Lines ��1. __.�_. Length of each lin ............................ Y (y <br /> E 1 � Material ....._ ... ._._........ <br /> t r ater' ✓ ca epth .Filter <br /> T ; <br /> 'D':Box _.__...----. Type Fil e / <br /> D ! Property Line ............... ...... <br /> Distance to nearest: Well _`. .. .. .:......... Foundation ..�-°-•--�-•••••- <br /> De th ` No Q <br /> SEEPAGE PIT [ ) p r Diameter­Z..-f -------------------- Diameter .....------..__. Number .........-..--•---------.-.. Rock Filled Yes ❑ <br /> Water Table Depth •. -•...............•••Rock Size ---•-------- ---. -.------------ <br /> , , <br /> Distance to nearest: Well foundation . .................. Prop. tine ....:................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# -----------7.11.-Q•fl--......... 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 cern 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 liven- <br /> ' sed agents signature certifies the following: <br /> "I certif at In the performance of the work for which this permit is Issued, 1 shall not employ any person in such manner <br /> as to ubject to IAfe 's Compensation laws of California." <br /> Sign d F - Owner <br /> 4 -------- Title -_---------------------- <br /> if other than owner) <br /> FO DEPARTMENT USE ONLY ' <br /> y..:' —q- 7 <br /> APPLICATION ACCEPTED BY ----- --- -� - - ----- ------- - �-- �-`-'--`I--�'--n------•--•...............---•--_. DATE �-._._r._..C-;-( -------`---- <br /> BUILDING PERMIT ISSUED -_-----­ -' <br /> SSUED -.._--- - -•--- -•-------•----•--••---•-.._...-..---- --•--- -------­----------DATE .... .............. <br /> •--•--- .. .....- <br /> ADDITIONAL COMMENTS ----- -- ----------- ---------_---- <br /> ------------------------------------------ <br /> --------_--- <br /> ------------------------- -•--••--------- -------- ------•-.-------- ----. --.... _.__..._._._.....-.... <br /> ..... _... f .... <br /> -----------------------...------•• •------.....-• •------.._-------....---...:------...--------------------------- <br /> ---- - - _. .._._ _..._ ..._Date _-- .............Inspection by: ------------------ - -- <br /> EH 13 2L 1--68 Rev. 5 SAN JOAQUIN tOCl�,tf'HEA DISTRICT 874 3H�f/{(�i//�)�/► <br /> Y <br />