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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PI~nT <br /> Permit No. .:7.7_= �.. <br /> IComplete in Triplicate? <br />� <br /> ...................----------------------------------- Date Issued ..�.'��:.�.� <br /> . .................................................. This Permit Expires 1 Year From Date Issued <br /> k ------------ <br /> Application <br /> - <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .:. ..... - --------.........__CENSUS TRACT ..�..�- ,_..... <br /> Owner's Name <br /> r' --•--....... -- --•--- •*.............. ...........Phone ..........................--........ <br /> Address .�. .. <br /> :...... City - � -•................................... <br /> c�.•� <br /> Contractor's Name _._. ._. .... . __.License # .A"hone .............................. <br /> Installation will serve: Residence tAportment House Commercial❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:.-_..1.._. Number of bedrooms _.__yGarbage Grinder ............ lot Size .......d ' <br /> Water Supply: Public System and name -----------------------------------------•----••-----•-- ...... -•••---••----•-•-••--••-•-•-• ........Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam e 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if.p1u�blic e.-Ir a7wer is available within 200 feet,} <br /> r}� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK e Size_�7 ..,. .�.._X..�_........... .. Liquid Depth ____ ........_ <br /> Capacity --- Type 60ii�►+. ...... No. Compartments _:_:__ _ .....••.. N <br /> Distance to nearest: Well -----------_ .:....Foundation :...� � . : <br /> LEACHING LINE No. of Lines ..--.- <br /> Prop. tine ....... <br /> (1� � g � � � g E <br /> .. ............ Length of each line----.,l.f C.?...'........... Total Length .__�•4�... .._... �. <br /> 'D' Box .... ..... Type Filter Material ......Depth Filter Material ._._._.-.� .........................:.... <br /> Distance to nearest: Well ......4 ----- Foundation <br /> undation ..../_0 ------- Property Line ..._-j _.... <br /> [ j <br /> Depth Dief e r,2..re14l). Number _................ Rock Filled Yes ❑ . .. <br /> •f 'Water Table Depth � -----Rock Size „ to <br /> �� //��� r /r , <br /> Distance to nearest: Wel( ....._�/ga ...............Foundation l/, ._...._ Prop. Line ..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ....------•.------•--------.__-----_.---- Date -_----------------­ ----------- <br /> Septic <br /> -----..----j <br /> Septic Tank (Specify Requirements) -----------•--•--•-------- -•---- -_------- ----------_----_-_---- •.......................-...... -•-•••........ ......... <br /> Disposal Field (Specify Requirements) •---•----- ... ........ ........ ._ --------------------------------------------------------_........... <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. Hoene 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 /> - <br /> ---------------------------- <br /> By ........................ . -. <br /> x. ......... ------------------ Title r <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B .. ..o... ...........................................................................•. DATE ............. <br /> BUILDING PERMIT ISSUED .....--••--•-•-•••-•--•---•--•-•••----•-••-•••_. _....--••••-•-••-------•. ------DATE'.....................---------------------- <br /> ADDITIONAL <br /> . ..ADDITIONAL COMMENTS .... ..................... ••......._...--••---•••••---._.:..---•••-••-.....-•-•-•--•...-•--.....-•-•-•....---•--..:-----•---r-----.......---....._......--••- <br /> ............... --------------------------------------I............. --•-•-•--••• •--•---•-• ••-•-••-•-•••----••---------------..............-•-•.......----••-•-••- <br /> ............................------------- <br /> ... ...... --------- -•--•-•...---••--•--...._........_...••••-••-:.............•-•-••....._....----------•-•-----...1. ..... <br /> •--..._...--••-•----••. ---- <br /> .. <br /> Final Inspection by, ... <br /> s;-��.... .���`'�.r,.............•---�-••--•-•--•--•---...............................Date _�:.� ....� --------------- <br /> r • SAN.:JOAQUIN LOCAL HEALTH DISTRICT <br />