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FOR OFFICE USE: <br /> - <br /> APPLICATION FOR SANITATION PERMIT <br /> ;Complete in Triplicate) Permit No --- <br /> ...................................................... _// <br /> This hermit Expires 1 Year From Qate Issued Dote issued A� :`-./7. . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> descri . T is pplication is ma in cant !lance with/County Ordirjance,n. 549 and isting Rules and Regulations. <br /> g <br /> JOB OCATION ... f '?.._ i '�!C'�/� I/!! ..-.� ..CENSUS TRACT .......................... <br /> Owner's Name ....... _.e ... ._ ..Q !_, ......... �.. .1 � arc _ .!� Pho <br /> Addressl .................... City c�,r:---------•--- -........•._.....- ---................... <br /> Contractor's Name .......License # .. Phone <br /> Installation will serve: Residence OApartment House)] Commercial OTrailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:._._.I.___.. Number of bedrooms ....Garbage Grinder ............ Lot Size .._ .V..............� <br /> Water Supply: Public System and name .--- ......-••--------- .......... --------..____...._...............................................Private <br /> Character of soil to a depth of 3 feet: Sand)] Silt❑ Clay ❑ Peat❑ Sandy LoomW Clay Loam ❑ Q <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 pu4lic s7wer is available within 200 feet,) <br /> PACKAGE TREATMENT t ] SEPTIC TANK Sias.... ............... Liquid Depth .- ...........•. <br /> Crf% . <br /> Capacity ._ .....----- Type _ . Material.-0x -.4.... No. Compartments ___2............ <br /> �' ( � r <br /> Distance to nearest: Well ....................................Foundation ...�..-®-•--------•- Prop. Line:_•--/�.-•---•.-' <br /> LEACHING LINE No. of Lines _... ------------- Length f each lin e.____(V_.._........... Total Length .....1. ..'......-. <br /> 'D' Box ---)------- Type Filter Material .. ......Depth 'Filter Material .../, ................................ <br /> Distance to nearest: Wel! .. � { : Fou dation .__..._.._ Property Line � .. <br /> SEEPAGE PIT [ ) Depth Diameter ................ Number ..._.....__._ .............. Rock Filled Yes ❑ No (] <br /> Water Table Depth .......... .....................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date _.._............... .............. <br /> Septic Tank (Specify Requirements) ----------------_-----------:.............. .................•................... <br /> Disposal Field (Specify Requirements) ...... ----•-------_---------• -------------------------------------------------------____------.----------• --------- <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 Son Joaquin Local Health district. Nome 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 sublet WorkTa 's Comp cation laws f California." <br /> Signed _ k. _ �----- .=Ow <br /> BY ..............•-•---------:--.. .. -----...._-.-..._..----- - ...... Title ... ,� <br /> {If oth than owner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __. ................................. DATE -..-`�__..-_-.--.._._.-- <br /> BUILDING PERMIT .ISSUED ......................... ..................................DATE <br /> ADDITIONAL COMMENTS ....... .... !.r/ .--•___-- -•-• <br /> A. <br /> .......................................... <br /> ............•................-............-•..............•---........----...........-•-----•-••----------•--•-------•--............----------................---...---................__._._..__..._... <br /> ..........................................I.... <br /> . <br /> --------------------------------------------------------- -- --J <br /> - <br /> 1 <br /> .�...-•-----------------------•----••--••-=---...._..----•------•----•---•--=----...........Date ...... <br /> Final Inspection by: ............... _.... _...._lf.�__.._..----....-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT P <br /> 13 24 <br /> E. H. i-'68 Rev. 5M 7/72 3 M <br />