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FOP,..O ...FFICE USE: APPLICATION-FOR SANITATION PERMIT <br /> ... . <br /> ..... ................ Permit No. <br /> lComplete In Triplicate) <br /> ...........I.................... Date lssued ,,'� ----- <br /> — --- 7C <br />............... ......................................... This Permit Expires I Year From Out*Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrt;d and install the work heroin <br /> described. This application is made in comp)/rice with Cou y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCA ................................ ----------CENSUS TRACT .......... <br /> -•- - <br /> / � <br /> ... .-Phone <br /> Owner's Name ... .. ......... .. ........ _._7------ <br /> --------------- ----- <br /> - - ----------- ---- <br /> Address ...............7.--- C11 .... ........ . .... ............ ........ ...........I................. <br /> .......... <br /> Contractor's Nome ... ------ --- --------- ...... ------.License# phone <br /> Installation wilt serve.* ResidencA Apartment House 0 Commercial OTraller Court 0 <br /> Motel 0 Other ------ .......................I-------- <br /> Number of living units:--- .... Number of bedrooms _.__..Garbage Grinder ........4... Lot Size ......... <br /> Water Supply: Public System and name .................................................. ...................................................Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Pe-at 0 Sandy Loom 0 Clay Loom <br /> Hardpan 0 Adobe Fill Material ............If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be places! ion*reverse side.) <br /> NEW INSTALLATION: (No septic tank or sw"pa W—pirpermittod"If-public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK I Size....................... ----------- ------------ Liquid Depth .-..._..-------_--..__-- <br /> Capacity <br /> Capacity --------------------• Type .........=----:-----.----- Material.........------- ...... No. Compartments- ----------------------- <br /> - . . _ <br /> Distance to nearest. Well '...-e' <br /> *_­....... .Foundation...................... dation ..... ............ Pro . Line <br /> Prop. .......... .......... <br /> LEACHING LINE Na, of Lines ........................ Length of each line,...---....-0 .1...... <br /> ......... Total Length ..... ------_------------- <br /> V Box ------------ Type Filter Material ....................Depth Filter Material ..........................I............J. <br /> Property Line ....... --_---------­ <br /> Distance to nearest: Well ........................ Founclation�---------�.t--------_-- <br /> SEEPAGE PIT Depth --------------------- Diameter _--------...... Number --------;,-I----------------- Rock Filled Yes 0 No 0 <br /> Water Table Depth --- <br /> ........... ...................Rock Sizie .................... ......... <br /> Distance to nearest. Well ........................................Foundation .......... ......... Prop. Line ..... ........... .... E <br /> Date <br /> OEPAIR/ADDITION(Prev. Sanitation Permit# ........................... ............ - ---------------------------------- <br /> • <br /> Septic Tank (Specify Requirements) ..... -1.._.­.1Z..................................................... -------............... <br /> Disposal Field (.SS �cify;tuiremenls) ---- -- --- --- ---- Lilt-" --------_----------- <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 he done In accordance with-Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HealW131strict. Nome owner or licen- <br /> sed agents signature certi les the following: <br /> "I certify that in the perforlpante of the work or which this permit is Issued, I shaft not employ any person In such manner <br /> as to becom f ubject bLWrkman's Compen tion laws, of California." <br /> ........L2T---- <br /> Signed ----- ------- --- ----- - — .......... Owner <br /> .......... . ... ... <br /> By --------------- ............. . ...... itle <br /> ----------------------- --- ---- ............................ <br /> (If other than owner) <br /> FO jt DVARTMENT USE ONLY <br /> h <br /> APPLICATION..ACCEPTED BY ----- <br /> -/_ . �!-__ _.-___.-I� -W_ ---------------- DATE. <br /> BUILDING PERMIT ISSUED ------------- -------------------------- ...... .......1�........................DATE ........... ............... ............... <br /> ADDITIONALCOM7N ............. - --------- .......... ----------------- -----------_------------I------ .......... ------- ------- -------_-_----_---------- <br /> -------------- - ----- <br /> .......................-- --------- <br /> ---------------------------- --------------------------------- --------------- ---------------- ------ ---------------------------------------------------------- --------- <br /> q &�' - <br /> ............ ---------------------------- ------------ ------- ------------- - ------------------------------------ ­­­ ;� - ------------------- ............. <br /> Final Inspection by. ........ ... -------->�7 <br /> v- <br /> -------- ......... ................Date ......... <br /> Elf 13 24 1-68 Rev. 5M // <br /> SAN JOAQUIN LOCAL HEALTH TRI& 8/7h 3M <br />