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FOR OFFICE USE: -j '• <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- --•----- <br /> {Complete in Triplicate) Permit No. <br /> ---------------------------------------------------------- <br /> This Permit Expires ] 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 th mein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rule a latio s: <br /> JOB ADDRESS/LOCATI � �_. - ----- --- -----------------------CENSUS T CT _-- ---- ----___- <br /> ti <br /> Owner's Name -- � - - -- -- - ----------------------•----•-----------:--------- �------ --------------Phone ----------------- ------ <br /> Address ` <br /> --�w_. _. City <br /> ---- - - - ------ - -- <br /> -- ---- ----- <br /> �._ 4°3----- Phone ------------------------ <br /> Contractor's <br /> Name - 1 , <br /> Installation will serve: Residence [!Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:------- ___ Number of bedrooms 3-------Garbage Grinder ------------ Lot Size ---.---____---_-- <br /> Water Supply: Public System and name --------------------------- --------------------------------------------------------------•------------------Privateffr <br /> Character of soil to a depth of 3 feet: Sand'0 It❑ Clay E] Peat❑ Sandy Loam ,E] Clay Loam F <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 seeppcje pit permitted if pybljcsewe�r is available within 200 feet,) , \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANKI J Sized/ 1-r_rS________________--------- Liquid Depth __$-/_____-___-_____-__- �N <br /> Capacity l::�46 ---___ Type -��-�e_ Material_ 1 ___r No. Compartments �_---__i__________ <br /> Distance to ne est: Well _______________ __________________Foundation ------Z-0 Prop. Line5____________.__ <br /> f <br /> LEACHING LINE [AT"' <br /> No. of Lines ____—------------ Length of each line______jQ4__I_.__.___ Total Length <br /> 'D' Box __ ______- Type Filter Material ____�_ _______Depth Filter Material _____ ----------------_______ <br /> Distance to nearest: Well---------- <br /> Foundation ----- ------------- Property LineT_S' ___ <br /> 'Z 5-__--_____ Diameter ___3.3_ __ Number _________ _ <br /> SEEPAGE PIT [ Depth -__._._ ------------ Rock Filled Yes �No i❑ <br /> s a <br /> Water Table Depth -------------9— ---------------------------Rock Size __ _X 3A_--------- <br /> Distance to nearest: Well -------------L_C_?D-----------------.Foundation _--_________ Prop. Line __:__._____ <br /> RlEPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------- ----------------------------------•------------------------_-- <br /> Disposal Field (Specify Requirements) ---------- -----------------------------------------------------------------------•--------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <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 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, I shall not employ any person in such mann �. <br /> as to become suble to Workman's Compensation laws of California." <br /> Signed -- ---------- Owner <br /> % <br /> BY ------ Title y Q- - ( $----------------------------------- <br /> _ <br /> (If er than owner) <br /> 47 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ __ - - <br /> -- -- ---- ---- -------------------- -- - --------------------------. DATE ------- -- <br /> BUILDINGPERMIT ISSUED ------------------------------------------ ------------------- ------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------- --------------------------- - ------ ---- ---- --- <br /> ----------- ---------------------- <br /> ------------------------------------------- ------ --------- - <br /> ------- - -- <br /> ------------------ --------------------------------- ------------------------------------------------------- <br /> ----------------- -------------- ----------- <br /> ---------------- <br /> --- --------------------------------------------------------- ---------------- <br /> Final Inspection by: Date __ _ `7._ <br /> - - ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b$ Rev. 5M # ' <br />