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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) -AT <br /> Permit No. . <br /> ............................. ........... — <br /> ............. This Permit Expires 1 Year From Bate Issued . Date Issued .. .�..... . . <br /> Application is hereby made to the Son 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 /> J08 ADDRESS/LOCATION TRACT ............ <br /> __,. . . Y :.....: ..Phone <br /> Owner's Name .. --••-••=• ........ <br /> Address ............... .1.......r��!+f�/r. �'.. Cit . . <br /> /f. Y <br /> Contractor's Name ._ _ .. ..._ .. ��._.!/��_ . r <br /> License # ........................-'Phone ............................... <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel C]Other <br /> Number of living units ............ Number of bedrooms .............Garbage Grinder ............ Lot.Size ............. r <br /> Water Supply: Public System and name .. --•---••---------------------------------._.:,.._._._..... ............::......:.................."....Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ ..Clay' ❑ Peat❑ Sandy Loom ❑ Clay 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 j,s <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> a <br /> PACKAGE TREATMENT [ j SEPTIC TAMC facit ] Size--------------------------------- ..:------. Liquid Depth .- ........... <br /> Capacity Y .....:.............. Type .................... Material-----------------..... No. Compartments ................... <br /> Distance to tnearest: 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 .. : <br /> ... ...................... Rock Filled Yes ❑ Na k <br /> Water Table Depth ................................................Rock Size ------------•-------- <br /> Distance to nearesT: Well .........................................Foundation .................... Prop. :Line --_--•--__--'_.-..._:. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ---.--­­--------­----­---- <br /> Septic <br /> ...- ---.---.....____..----Septic Tank {Specify Requirements),...............................................................• •-- -- <br /> Disposal Field (Specify Requirements) .•,� ,rte-' .-'---------.� / �_........ . ........... : ............................•--••-• 4 <br /> --------------------------------------•--••--------._.-...� ...............................•--..........•-----.....---• 07-•............................... <br /> . .. # <br /> .i. � i <br /> --- .. <br /> 1 � <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 Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify th the erformance of th ark w ch th' ermit is issued, I shall not employ any person in such manner <br /> as to beco bi to Workman's C mp ati.on I of alifornia." <br /> Signed _ Owner <br /> ..... ••. ----- --------------•- <br /> BY ........................................................ -- Title <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , t ........................•-•----.....:..................--•--•..... DATE c<7­".1.!W.-.,?y-- -- ............... <br /> BUILDINGPERMIT ISSUED ......... =.............----............................................................... ........DATE _.. ............................... -•-----• <br /> ADDITIONALCOMMENTS _._._..---••-----T..........................................................................•---• --••---•.._....._....._._...._.:........._................. <br /> :4 <br /> ......................................... .....•----... ... .._..... . .-•---•--...._.....................................................-------•--•---•---- <br /> ....._.._.............................._....................-••-.....------...•--••-----•-•----••--...--...---• .......................................-.......................- ••--•--•-- <br /> Final Inspection by: :.. ......:............. .•-•......................................................Date �a �. . ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> E_ H. 13 24 1_'6A RPv. 5M 7/72 3 M <br />