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F4 OFFICE USE: c t72. Gt o lid, <br /> - - APPLICATION FOR SANITATION PERMIT <br /> ................................ 77 <br /> .., ► .... Permit No. ..................... <br /> tCemphft M Tripiitatal <br /> Thls Permit Expires 1 Yew From Deft issued Date Issued .. ' .. <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 Regulotionst <br /> JOB ADDRESS/LOCATION .....,I ............ ...............................__........ ....CENSUS TRACT . ............ <br /> Owner's Name �� k. !..C..: . . .. � <br /> .... ...... <br /> .....�. ..� ... ............................._. ... � ... Phone J s <br /> Address city ...... .. .... x <br /> ` /sr....., <br /> Contractor's Name .................................•--------------•----••. •-----....................license # ........................ Phone .............................. <br /> Installation will serve: Residence❑Apartment House 0 Commercial)]Trailer Court 0 <br /> Motel®Other............................................ <br /> Number of living units:----.---_- Number of bedrooms _4A•....Garbage Grinder _---- Lot Size --. _2 ..................... <br /> Water Supply: Public System and name ........................................................._...................................................Private Q <br /> Character of soil to a depth of 3 feet: Sand E] Silt Q Clay ❑ Peat❑ Sandy Loam D Clay Loam j <br /> Hardpan Q Adobe❑ Fill Material............ If yes,type............... ............ <br /> �r•��rrrmsrur,�rrer�r�srn���r��r�i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be plated 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[ ] Size................................................ Liquid Depth .......................... <br /> Capacity -------_-------_ Type -------------------- Material......---- ........... No. Compartments ............... <br /> ...... <br /> .�I1 <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......_..___.._......-\ <br /> LEACHING LINE [ ] No. of Lines ...... ................ Length of each line............. ............ Total Length ............................ <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearrp1t: Well ........ ,.� ... Foundation ........................ Property Line ...`...................... <br /> SEEPAGE PIT ( j Depth _: . ...... Diameter �L.:.,�.2... Number .............�............. Rock Filled Yes j No a <br /> �._...�._ Water Table Depth .............................. •--•...._ <br /> . ................Rock Size ....-•--• -- - <br /> Distance to nearest: Well_--.-/4.....►'n.l.L ,...........Foundation ...... ........... Prop. Line ........ .......... <br /> REPAIR/ADDITION(Prov. Sanitation Permit -............................................ Date <br /> Septic Tank (Specify Requirements) .....................'.... .-- .r. ..... ....._.... ............................... s........_................ <br /> Disposal Field (Specify Requirements) ........................................................... <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 Sen Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Me" District. Nemo owner or )item <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 M such manner <br /> as to become subject to Work a 's Cempen on laws of California.,, <br /> Signed` . 1. �Z �,P.. ....... 7, . ............. Owner <br /> BY /-----•----•..........................................•---•-- ._.. Sitle .-----------------................. ............................. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> oil 01 APPLICATION ACCEPTED BY ... -- - - • . . . <br /> ..... -- . ©ATE ... -' `!t?7 <br /> BUILDINGPERMIT ISSUED ......... . ........................................................ ..---..DATE ---...-----------------•-------------- <br /> ADDITIONAL COMMENTS .---- . -----_......................... - _..-....... <br /> -------------------------- ..........------...............................................................•-_-........................- -................. -------- ........................ <br /> -........................ ----•-•• -- --- -- _........................ <br /> .:.. ----- ........,.._.................... ............................. . <br /> ..._- _., ..-. _ .. <br /> ........................ ..._._ .. .....__. ..._ . _.... ...... ... ...._..,......_.,,..,.. ........_......._. ..Final inspection by: . - - _..........................:....Date .....Q .a--' ..,'1....... <br /> EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />