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f FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. 7.7.............. <br /> Complete In.Triplicate). <br /> F............ .............. p Date Issued <br /> .... ...........•--•--........ <br /> This Permit Expires t Year from Date issued <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. 549 and existing Rules and Regulations: <br /> /__-_�.....:.:..::....... ... ...�ENSUS TRACT <br /> f JOB ............... <br /> . � <br /> iOwner's Name -7 ' ..... <br /> �--.._.__. �.................... _.....Phone <br /> eA , � City ..................... <br /> .... .............._-_--- <br /> Addr <br /> Contractor's Name License # .........;.............. Phone .............---.._........._. <br /> Installation will serve: Residence A. artment Houser Commercial QTrailer Court 'Q <br /> Motel ❑Other ... ...... ................... <br /> Number of living units -.Y Number of bedrooms Gafbage Grinder _........... Lot Size g '- <br /> Water Supply: Public System and name --_ -__.-„___--......................___-.�___. ...................................... Private <br /> .Y_ --- _. n.�_ ' <br /> Character of soil to a depth of 3 feet: Sand Q Sift Q Clay Q Peat Q Sandy Loam Q Clay loam <br /> Hardpan Adobe Q Fill Materia!............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-1 <br /> NEW INSTALLATION: (No septic tank or seepag"It-}permitted-if-public sewer is available within 204 feet,) <br /> I <br /> PACKAGE TREATMENT [ l SEPTIC TANK I I Size..........................................••.... Liquid Depth .......................... <br /> � Capacity --------------- Type --•----------------- Material...•.................. No. Compartments ....................... <br /> -� Distance to nearest.• Well ..Foundation --_--__.-_-......... Prop. Line ...................... � <br /> LEACHING LININ [ ] No. of lf ines ........................ Length of each line............................. Total Length .-_------_-_--•-•__...... <br /> 'D' Box .........'. Type Filter Material .................._Depth .Filter Material -------------__-........................... u <br /> Distance to nearest: Well -_ ..... Foundation ............ Property Line ........................ <br /> SEEPAGE PIT [ j �. . Depth .................. Diameter ................ Number ............................ Rock Filled Yes 0 No 0 <br /> Water Table Depth ----------••--•-- .............................-Rock Size :-------------------------- <br /> �1 <br /> Distance to nearest: Well _....:--__...Foundation .................... Prop. Line ,..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit c# -----=-•----- •---••--•••--------- Date _..:---•------_-_---__------) <br /> ..f <br /> Septic Tank (Specify Requirements) --._:-_------------ ------------------ ----•- ......-----------:_........._,...................I-------- <br /> Disposal Field (Specify Requirements) ---fJ1JD------- ----�---._.. ......._..._.. y,..tr...........--�.......... <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 be done In accordance with San Joaquin <br /> County Ordinances, State Laws,:and Rules and Regulations of the San Joaquin Local Health.D[striet. Home owner or liven- <br /> sed agents signature certifies theFf_ollowing: <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 /> By ..................... -•--- ----------. --------- -Title -•------- ------- --------.......-....------------------------------ <br /> (if <br /> -------------- ----.- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.,.. - -----------------=---- DATE..�7� -. ..- ,.�,�._:.-. .... <br /> - ------- ............... <br /> BUILDING PERMIT ISSUED ` --DATE -- .......................... <br /> ADDITIONAL COMMENTS ------- . ........ ... .. ...........-...................................- <br /> -----------•------- <br /> a --- ----------- ---- -_---------------_---------- <br /> ------------------ -------------- --------- <br /> -----------------------------------------•-•---•---- --.........-.....------- -------------------- ------ -------- <br /> final Inspection by: . � - ---.....Date -•------ ............ <br /> EH 13 24 1-•68 Rev. ZM SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />