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FOR OFFICE USE, <br /> .................. .......... .................. APPLICATION FOR SANITATION PERMIT <br /> ..........................................g............. (Complete In Triplicate) Permit No. <br /> ....... ......................................... <br /> ThIS)POrmit Expires I Your From Dote,Issued Doti Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> application is made in compliance with County ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATI <br /> 0 ...... <br /> ...............CENSUS TRACT ..........I............ <br /> Owner's Name ..... .. <br /> ...... <br /> Address / ones. T.......... ...... <br /> 11"`���' .* <br /> Contractor's Name ....... .......... <br /> ------ <br /> 4 <br /> ?7:: Phone .............................. <br /> Installation will serve.. Resi 'once 0 Apartment House Q Commercial OTraller Court <br /> ❑ <br /> Motel El Other....... <br /> Number of living units_____________ Number of bedrooms ............Garbage Grinder ............ Lot Size ......-................. <br /> ............... <br /> Water Supply: Public System and name _. zti ...... ---%............... ..........Private.0 <br /> Character of soil to a depth of 3 feet., Sand t] Silt❑ CloTy 0 Peat[3 Sandy Loam Clay Loam 0 <br /> Hardpan 0 Ad be 0 Fill Material <br /> ... <br /> 0 ......... if yes,type <br /> ............... ............ <br /> (Plot Plan, showing size of lot, location of system In rotation to wells, buildings, etc. must be <br /> NEW INSTALLATION: — - placed on reverse side., 43 <br /> (No septic tank or seepage pit permitted If public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK <br /> Size_.....:......... <br /> ...........------------- Liquid Depth ........................1 4 <br /> CGPacitY ..............•----- Type ...... ------ Material....-----.-.... ........ No. Compartments ....... <br /> Distance to nearest. Well ................. __Foundation ..................... ...... <br /> LEACHING LINE No. of lines Prop. Line ........... .......... <br /> ------------------ Length of each line__.--- ............... Total Length • <br /> ..... ....................... <br /> V Box V1 <br /> Type Filter Material ..................Depth Filter Material ............................................ <br /> Distance to nearest: Well ............ <br /> - Foundation ....--•••.....I.....--_. .Property Line .......................J. <br /> SEEPAGE PIT Depth ---------------.- Diameter ---------------- Number ... ----------- ............. Rock Filled Yes'[3 No O�J-I <br /> Water Table Depth ----- .................. -------------------Rock Size .. ........................ <br /> Distance to nearest- Well ----------------------------------------Foundation ..... .............. Prop. Line ....................... <br /> REPAIR/ADDITIONIPrev. Sanitation Permit# -----------------------------•-...._.._.. Date ............................ <br /> Septic Tank (Specify Requirements). ----- <br /> t --------------------**--------- ------*....................... ------------- <br /> - -------------- <br /> Disposal Field Zeciyfyequirements)z?r---- --el-el-4...YJO�. aa2� <br /> ---------- <br /> ------ ........ <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 Son Jouquini <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local ReallK,011stdcl. Home owner or licen- <br /> sed agents signature certifies the following: i <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------ ------a------------ ........ ----7j� ----------------- Owner <br /> By ................... ......... ....... <br /> .. . ... .... .. . . . ...... Title <br /> (If other than owner) --....---••---•--------•-••--------------•- <br /> O <br /> ------ --------------------- <br /> 0 DRARTMENT USE ONLY <br /> --------------------------------- <br /> ­DA T E�e-:�7/ <br /> ............. <br /> APPLICATION ACCEPTED BY ------- <br /> I I RM <br /> T ISSUED <br /> ................ .......... <br /> --------------------- ---------- DATE--. <br /> BUILDING PERMIT ISSUED -------------- ------- ---DATE ........... <br /> ADDITIONAL COMMENTS ----------------------------------------------------------------- --------------------------- ......... ... ................ <br /> -..............................1---------------------I-------------------------- ...................--------..:----------....-•-------.... <br /> --------- ------*------------------ -------------------------- --------------------- ---------------------------------- ................................................ --------...................... <br /> ......-.......... ------------ ------------------------------------------- -----------------,-----------------------------•---------r ---•------- ........ <br /> --------------------------- ---------- --------1-..........--..........-------- .............................. <br /> Final Inspection by- ------ ------- -------------- ------------ .............. . .. ........... <br /> ... .... -------- - ---- -- Date ..... <br /> ------*-- -- -------- - -- - -- -- -- --- - --- ---- <br /> EH 13 2L 1-68 Rev. 5M SAN JOAQU'I'N'-'LOCA'L-'H-E-A"LT-H"DI-S-TR*ICT.............. <br /> 8/741 3M <br />