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FOR OFFICE USE: <br /> (CompleteR SANITATION PERMIT <br /> ' 3 APPLICATION FOR <br /> 1. Per No_ ________________ <br /> in Triplicate) <br /> -------------------------------------- <br /> Date Issued -,F-- <br /> ------ -- ------- --------------------------------------- <br /> " -----------------_---..------.-.-.-----_----------------- ;,, This4Permit ExpiresA Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health bistrict for a permit to con`stziuct andrFinstaII the.work herein <br /> described. This application is made in complian a with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __1�_ � `�. ---- - - - ---- - - ----------------------- --- CENSUS TRACT -------------- ------._--- <br /> Owner's Name --------- Phone -- Ga7 <br /> --- <br /> 4 <br /> Address -------------- ----------- ----------------- ---------------------------- ---- - ---------- <br /> ��Contractor's Name ---------------��-- - -- � --`f'-- - - - - �----------------- -� .. # ------------------------ Phone �� -- -=-, -0• ----- <br /> installation will serve: Residence ❑Apartment House Commercial railer Court I❑ <br /> Mote! ❑Other -------------------------------------------- <br /> Number of living units:.----------- Number of bedrooms ------.----'-',-Garbage Grinder ------------ Lot Size ---- --------_---- <br /> Water Supply: Public System and name ---------------------------------------------------------'---------------------------------------------------PrivateX <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay"Loam 'E] <br /> Hardpan ❑ Adobe Fill Material ............ If yes,type ---------------------------- <br /> Ar <br /> (Plot plan, showing size of lot, location of syste_m'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,J <br /> PACKAGE TREATMENT { ] SEPTIC TANKf[ ) ;, �_ ize_.______�_ __ Liquid Depth -------------------------- <br /> Type <br /> ____ <br /> T e __ __.____ t---_ Material. i�t� No. Com artments <br /> - <br /> CapacitY J { Yp - . <br /> Len AC----------------------- ----10_ ---- Prop. Line ----------_---------- <br /> LEACHING <br /> ---1---_ -------- <br /> + Distance to nearest: Well ------9�� r � _ � <br /> LEACHING LINE [ ] No. of Lines of each line---- gth �.-------------- <br /> 'D' <br /> ..___ _ __ <br /> f Tota! Len - . ___.. <br /> r� <br /> f <br /> _ _ -----Depth Filter Material -------��----------------•------------ <br /> Distance to nearest: Well <br /> tergal Foundation ____ ------------- Property Line --�`-d................ <br /> SEEPAGE PIT Depth Diameter 33_F__ Number ----------- -------------- Rock Filled Yes No <br /> .Water Table Depth _ ------------------------- _ ------------_-----Rock Size __/! u_r. � <br /> Distance to nearest: Well ------{ ------------a--------Foundation --C-Q-------_-_ Prop. <br /> Line .../0------------ <br /> REPAIR/ADDITION <br /> --___.-___-REPAIR/ADDITION ------------------------------------ t <br /> (Preva Sanitation Permit# -------- ------------- ------ Date ---------------------------------- <br /> SepticTank (Specify Requirements) -----------------------------------`----------------------------------------------------------:------------- .--------------------------- <br /> Disposal Field (Specify,Requirements) ------------------------------ --------------------------------------------------------------------------------------------------- <br /> - '----------------- ------------------------------------------------------------ ------------------------ <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 manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----- ----------------- -------- � Owner <br /> BY - -------- -- ------r---lam'-- - ------------------ Title ------.at------- ---------- <br /> ------------------------------- <br /> (If o r than owner) <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTEQBY ---------------------------------- QATE __.� .- -------�--- ------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------ ----- - ---------DATE .------------------------------------------ <br /> ADDITIONALCOMMENTS ------------- ----------------- ----- ----------'----------------------- -- ---------- -------------------------------------------- ---------------- <br /> `" -- - <br /> ------- <br /> - - ------ - ---------` - <br /> Final Inspection by: = V----------------------•----­_------ -Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M, <br />