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L <br /> i FOR OFFICE USE: APPLICATION FOR SANITATION P'ERMI'T <br /> ............................. .....................I... Permit No. 5�..`Q7 <br /> (Complete In Triplicate) <br /> ...............................................•......... <br /> ........ ... .. ....................... ..... This Permit Expires 1 Year From Dote Issued Date Issued ..��....... <br /> ....... <br /> Application is hereby mode 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. 540 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ... �� .... .............. ..CENSUS TRACT .......................... <br /> Owner's Name ......... --J'T...�.. ... ...... ... ....Phone .................................... 4 <br /> Address /. ,� _ .......... City .. ............. ................... <br /> Contractor's Nome /� / ,�• <br /> License # Phone <br /> Installation will serve: Residence Apartment House C] Commercial ❑Troiler Court C <br /> Motel ❑ Other _. . <br /> Number of living units:-... Number of b roo ......Garbage Grinder-15�17Lot Size ./� ." ��t/ <br /> Water Supply: Public System and name . .. int/�. ........... . . ......... ...... .....Private ❑ <br /> Character of soil to a depth of 3 feet: Sand p Silt❑ Cloy ❑ Peat❑ Sandy loom ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeFill Material . . . _ if yes,type ...... . .. .... ........ <br /> (Plot pian, 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 /> ... ... <br /> PACKAGE TREATMENT [ ] SEPTIC TANK j <br /> ...-......... .... ...._... _... liquid Depth .......................... 1 <br /> Capacity . ..... Type . .... . Material........ . . ........ No. Compartments .......................,r <br /> Distance to nearest- Well . ......................... .... ...Foundation .... _ Prop. Line . ................... i <br /> LEACHING LINE (jd No. of Lines . ... . Length of e ch liTotal length <br /> D" Box, - Type Filter Material Depth . .��1 ............: <br /> ✓ ` Filter Material. <br /> j <br /> Distance to nearest: Well Foundation . Ila-..�. ... Property line .. <br /> .. .... Rock Filled Yes No I <br /> SEEPAGE PIT :( Depth ����_. Di eter �.!-�.�.. Numbs• . ..-�........... ❑C <br /> ` Water Table Depth �0-. .. ....Rock Size ............ -- <br /> Distance to nearest: Well ..�j�� ._Fourulation .�.... Prop. Line ... �� .• .....� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# . ...... .... ................ ............ Date ...................... ........ <br /> Septic Tank (Specify Requirements) :.. ......... <br /> Disposal Field (specify Requirements) ... . .. ...... Lr..''o'`:... � •• �'�+''"��/'�'`-.. <br /> .... <br /> .. -. _........................... _ �� _ r _ �................... ........ ................................ <br /> ............................... <br /> ............................. <br /> .... ..... ........... ......... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 LeeW Wealth 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, 1 sha not ompley any person In such manner <br /> as to become subject to Workman's Compensation laws of California." j <br /> Signed . . . ... . __........ .. _... ..... ....... Owner <br /> By . . <br /> Title f <br /> -..-.... <br /> (If other than owner) <br /> R DEPARTME USE ONLY <br /> APPLICATION ACCEPTED BY ... . DATE a <br /> `J............ .. . ... <br /> BUILDING PERMIT ISSUED ......... . .. . ... . .. .. . ... . .............................. .. .. . ..... .DATE . ................................ ...... i <br /> ADDITIONAL COMMENTS . ................. ... ........ ...... l.. ........ ...........I....................... <br /> ........................... .................................... ... _.. _ ... -. / /y, .................................... <br /> ......... ...... ............... --r- <br /> Final Ins ection by: <br /> P Date ... .,r,�. ..'.... ..... <br /> SAN JOAQ1UI LOCAL HEALTH DISTRICT T <br /> E. H.13 24 1-'68 Rev. 5M 7/723 .K <br />