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FOR OFFICE USE. <br /> /U 3d / y� APPLICATION FOR SANITATION PERMIT <br /> ............................. <br /> (Complete in Triplicate) Permit No,21.41 <br />....... ................................................ <br /> ..... .... --------------------------------- Thls Permit Expires 1 Year From Date Issued Date Issued la:/dam 7 <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 compli nce h County Ordinanc KPo. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATIO / ......... �...........................CENSUS TRACT ......................... <br /> . <br /> Owner's Name -. ... .. ...... --.....: ..... -Phone .............•--- �--,r� <br /> ...... <br /> Address .- ................ ...... - ..... ----- ....City ............... ........... <br /> . ..... <br /> Contractor's Name ..........L-0ms--- --------- ---:......... ._.:..� .. License # ......... Phone ......................-, <br /> installation will serve: ResidencegApartment House 0 Commercial ❑Troller Court 0- <br /> Motel [3 Other ................ ........ ..................:! �� <br /> Number of living units:,-.. -...... Number of bedra s Garbage G e L Size .., � ..� .............. <br /> Water Supply: Public System and name ........ --:- Ax.t...................Private C] <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay' ❑ Peat n Sandy Loam,0 Clay Loa <br /> Hardpan ❑ Adobe'Q Fill Material .-..-:. If yes,;type --•--'---------------------(Plot pian, shbwing size of lot,,location, ofsystem`. in relation to.wells, buildings,. etc.. must be placed.on reverse .side.) ,_ <br /> NEW INSTALLATION: ' (No septic tank or see age p' permltted if public sewer is available within 200 feet,)Size <br /> PACKAGE TREATMENT J SEPTIC TAN .:.!7` .. ..�p. .. .:.-. Liquid Depth .- -•-.•_--- ! N <br /> Capacity .... .. ..:.... Type` ' ........_... Material. `.... No. Compartments ... .. <br /> Distance to nearest: Well ..- $?ti ............Foundation ....A ... Prop. Line`............ <br /> Length of each line.-. .... Total Length .............. <br /> LEACHING LINE No. of Lines ....�........_... ..�.:,. .. <br /> 'D' Box .... ...... Type Filter:Material($ : ... :..Depth 'Filter Material ..................... <br /> Distance to nearest: WellFou ation <br /> -..._--- ----"-=-==-----" Property .. <br /> Line ....... . .......... <br /> n � � <br /> SEEPAGE PIT ( Depth ;, - �:.____ Diameter : fir'.... Number .:._.�, -:.._.�:..� ...•..'Rock Filled Yes �.. No (:1 <br /> Water Table Depth .. ......................Rock Size ....:.. <br /> 1 <br /> Distance to nearest::Well . ?.► ....................Foundation Prop. Line ' ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........... ..........................:..... Date ...........:......................) { <br /> .Septic Tank (Specify Requirements) •---•....................................... ...--•-------•--•--.:...................:_.............._.............._............... <br /> :Disposal Field (Specify Requirerhent ------ ....:--_ ......:...... <br /> ~ � <br /> .................... ------.......................--..--. .._......... ..... . — - .......... <br /> (Draw existin..and require addition o re erre side) <br /> I hereby certify that I have prepared this application and That`the.work will be donein accordance with San JoaquinF <br /> County Oirdinances, State Laws, and Rules" and Regulations of the San Joaquin Local Health,District. Home owner or How' <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 sub'ect to Workman's Compensation laws of California:" ; <br /> Signed <br /> BY .............................:...:..�...::...:. rn1 -- Title : . ---------------------. -•--•-------- ...... <br /> (If other than owner) <br /> F #ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...L. :_.:::..............................................= ... DATE ....... <br /> .. I <br /> _ _BUILDING PERMIT ISSUED ..... -- .. .....:. .. ..... .. ......DATE ..........:................ .._ ... ....:.... <br /> AQDiTION COMMENTS r.. _ ........................... <br /> ...._, <br /> ..... ......--: <br /> - ._ - <br /> Final inspection by ..................:......:_............_ .. Date ....... <br /> �r <br /> _ SA OAQUIN' LOCAL HEALTH' DISTRICT _ <br /> E. H.13 241•'68 Rev. 5M _ -,w..._._ . .... .._ .. . ». _..,. . __w. ,...... .. ,....... ..._... ...-.� ..,�.,.,.7 172 3 24 <br />