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4 <br /> .. <br /> F.oa. ..oFFIC. . . I: usE. . .... <br /> APPLICATION FOR SANITATION PERMIT � 72 y <br /> .............. .. . .. . . .... . . . .-�•---•----.. ... <br /> {Complete in Triplicate) Permit No. <br /> ..................................:..................... <br /> ....................................... This Permit Expires 1 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 the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations.- <br /> JOB <br /> egulations:JOB ADDRESS/LOCATION .4_4 �_.....�r----- , <br /> -- �..�. . ----------------------------------CENSUS TRACT .......................... <br /> Owner's Name .�.�" .,..... _-------------------- . ~..........., ------- <br /> .Phone ........... ................ <br /> Address ..---- •------� ..�-..--.��--------- -- - ----- --- - ---- -- City - - . ..... . ----......-------- ............... <br /> Contractor's Name . �. �L ��s ,2 ...........License # -/J_31F>- Phone .............................. <br /> installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ...................• -- .............. <br /> Number of living units:.. ..y Number of bedrooms _J�----._Garbage Grinder ............ Lot Size -._. ... ------ <br /> ....WWater <br /> ater Supply: Public System and name . ................. -------------------.------- ------------_-_---.-..-..... ----------Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay E] Peat E] Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _........... If yes, type ....... ...... --. <br /> (Plot pian, 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 /> j 7 . ] Liquid Depth ................... <br /> PACKAGE TREATMENT SEPTIC TANK Size........................................... .. <br /> Capacity .. Ipe -------------------- Material...... No. Compartments ------..--............ . <br /> Distance to nearest: Well; . ... .............................Foundation .... ........ Prop. Line ........._.--_-._--... <br /> LEACHING LINE [ ] No. of Lines Length of eachline. .......... Total Length .... ....................... fi <br /> 'D' Box Type Fil�te'r Material ....................Depth Filter Material ......-.................................. <br /> .-- <br /> Distance to nearest: Well ------------------------ Foundation . ... __............_... Property Line .......... <br /> SEEPAGE PIT ( j Depth .. . .- Diameter ---------------- Number Rock Filled Yes ❑ No ❑� <br />` Water Table Depth .............................._-----------------Rock Size ................................ . F <br /> Distance to nearest: Well ------------------------------------------Foundation ----------- ------- Prop. Line .-.................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date <br /> 101 f 4 <br /> ...........----- _-------.-.-.----. <br /> Septic Tank (SpeafyRequRequirements) . .... ..___.... .._:_. _. _..... ----------------------------- 1 <br /> ...------. <br /> Disposal Field (Specify Requirements) ..... . .... . . = <br /> .................. <br /> a <br /> ........ --- lea._ -...-- - -- --- . <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. Horne 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 manner <br /> as to become subject to Workm Compensation laws of California." <br />! Signed .... ..............�__........---. ..... .._... ---- --•----•--- ----- Owner ..- <br /> 4 -lEf other than caner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .-- _. % DATE .,.� .......... ............... <br /> BUILDING PERMIT ISSUED ............... .. .. --- . ......_-•---------- , _--........,.:... ,..... ...--._ <br /> ...---•--------••--•............._...... .......--•----.,..DATE . ........-_.......-..----------:......... <br /> ADDITIONALCOMMENTS ..... ..................... ........ ........._..._..._.__...._._...-- ---- ..---....I..........------ .................................. .............. <br /> ........... . .­... ........__ _----------- -•-- <br /> ........................................ ___. - .._. .....--.~..--...- .. <br /> Final Inspection by: -• ........... ...... .•--•-. -- --.Date .. ... -1---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Z3 24 { 7/72 3`F-- <br /> E. H. i 66 Rev: 5M � - ---- --- -- - <br />