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rUK UrriLt u5t: - � •� <br /> APPLICATION FOR SANITATION PERMIT X77 <br /> . ... ...-- - <br /> - ------ ---- ---- --- ------ <br /> (Complete in Triplicate) Permit No: ---- <br /> This Permit Expires 1 Year From Date Issued Date Issued - <br /> Application is hereby made to the Son 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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TIO <br /> D : --_ ... -------- ---- -..CENSUS TRACT <br /> ZZ <br /> Owner's Nanm __�.� /--- --- --- - -- -- - --••-- -- . .. - . <br /> • -------------- Phone <br /> Address ------------ --- .............................. City --------------------- ............ <br /> Contractor's Name -- .-.License # -------- ------ Phone -------------_-----_------ <br /> Installation will serve: Residence ❑ Apartment House C] Commercial.❑Trailer Court <br /> Motel ❑ Other ......... ------- <br /> Number <br /> -----Number of living units Number of bedrooms .-.---------Garbage Grinder .... Lot Size aL.+�¢-�--• <br /> Water Supply: Public System and name ............. - ----- ----------------------- ----................. -------------.._._-Privote (� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ] Sandy Loam ❑ 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 public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 5ize4l� X14 �_�.�---_--__. Liquid Depth _ ................... <br /> Capacity 7��eorest. <br /> Type:.. .--___-- -'-_-- Material O�Y� '.---- No. _Compartments ..a---._.._...... 1 <br /> Distance to WeI�� �Q,/�___ __._._Foundation ._.. ------- Prop. Line -_.;ZQ......... <br /> 4�ln 00 <br /> LEACHING LINE ( ] No. of Lines ------'2 ----- Length of each line ........_.. Total Length ........... <br /> 'D' Box -------..... Type Filter Material ------ - _._..._._Depth Filter Material -.._... . _____________________.._--___ <br /> Distance to nearest: Well ........................ Foundation .._. Property Line _.------------ ....... <br /> SEEPAGE PIT [ ] Depth -----------------..- Diameter _ _____________ Number ------ --------- ....... -. Rock Filled Yes ❑ •No I❑ <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 /> ---- -- - --- -----------•-------------•----------------------- --------- ------ - - ------------------------- ------•------------------------ -------------I----------•.............. <br /> V <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 /> Sig Owner yy�� <br /> B _... _ . ------ ----- ------ <br /> (If other than owner) . /-7 7_ �/�2 7 ■ <br /> `� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.__{.... ._-__ _. --_ - __._. .... -_._ <br /> l!e- --/ DATE <br /> BUILDING PERMIT ISSUED --------------------- ----------- .....DATE --.._---•------------------------- <br /> ADDITIONAL COMMENTS ____________________________ _ _______________ _ <br /> -------------------- ---•--- ---------------- --- --� � �.� --------- <br /> ---------- <br /> - .� a� <br /> ---------- ................................... -- ------- -------------- ........ <br /> -------- ---------------------------------- _ .------------------- ----------- h <br /> - ------- ------ ---- <br /> . --•--------- <br /> Final Inspection b -e_� - - Date -2 " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />