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FC7R OFFICE USE: <br /> APPLICATION fOR SANITATION PERMIT <br /> ------ ---�f5------------------ Permit No. '�_3_'_�(� _ <br /> (Complete in Triplicate) <br /> ---------- ---- -------- ------------------------------- <br /> Date Issued 1-0__-�__�.�.3 <br /> -----------------------------------_--------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein ` <br /> described. This application ismadein compliance with County Ordinance No. 5.49 and existing Rules and Regulations- <br /> JOB ADDRESS/LOCATI N ._1-� � �:eo <br /> _ ----- -- 'c"/--------------------- -CENSUS TRACT -------------------------- <br /> 1-v-i�-------- �e--� ----------------------------------- --------------Phone ------------------------------•--•-- <br /> Owner's Name -- --------------- -,`�..-----�1----`� � <br /> Address ---- 1�.� �-------- /7 .�.�1 .✓------ ------- ------------ City �y�r --,------- ---------------------------------------- <br /> Contractor's Name + 0. --------------------------------------------------------------License # Phone <br /> Installation will serve: Residence, Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:-----I------ Number of bedrooms LGarbage Grinder ------------ Lot Size ___________________________________---.___. <br /> Water Supply: Public System and name ------2) S- -/-s4,:._____�'e-G/--------------------------------------------------Private ❑ <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 in200 feet,) , <br /> 11 <br /> PACKAGE TREATMENT { ] SEPTIC <br /> sT,ANK jq Size________ __...... igGt e p t h ----_�______- <br /> Capacity 1.lCr-D-___ Type __ Material o. Compartments -----2-.- <br /> Distance to nearest: Well _/ I_________________Foundation ... Prop. Line _77-7-77-77'....., <br /> LEACHING LINE [ J No. of Lines -------)--------------- Length of each line------I __._----- Total Length <br /> 1- �I f <br /> `D' Box ------------ Type Filter Material r44_1L__Depth Filter Material ____ ________________________________ <br /> Distance to nearest: Well _�nQ-------- Foundation ---------------- Property Line ---____�-------- <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ------ ----------.---------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------hock Size -------------------------•------ rn <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line _________- ........... <br /> LADDITION(Prev. Sanitation Permit# ........._t3'-M----A*-C'-------- Date __________________________________1 <br /> Septic Tank (Specify Requirements) -------------------- <br /> Field (Specify Requirements) ----------------•-------------------------------------------------- ----------------------------------------------------------------- <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 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 shall not employ any person in such manner <br /> as to becomes_Mbiect to Workman�mpen lawsof California." <br /> Signed - - ----- ------------------ ------ - Owner <br /> By ------------------------------------------------------------------------------------------------------- Title -------------- ------------------ <br /> - ----------------------------------- - <br /> (If other than owner) <br /> 11 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED $Y -- ------ ------------- DATE .--- - _ 3------------- <br /> BUILDING PERMIT ISSUED ------- - = -------------------------------------------------------------------------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------------•----------------------------------------------------------------------- --------------------------- <br /> ` <br /> ------------------------------------------ <br /> --------------------- ----------------------------------------------------------------------- ------- - <br /> FinalInspection by: -- - ----------- ------- --- ------------------------------------------------------------------------------Date -----� - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M W4 <br />