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FQR OFFICE USE. I'A_ APhICAT4,ON FOR SANITATION PERMIT <br /> r , <br /> Permit No.7/ <br /> ---------------- ----------------- --- - <br /> (Complete in Triplicate) <br /> ------------ _ This Permit Expires 1 Year From Date Issued <br /> Date Issued ___ ------ <br /> __ _ <br /> ------ ---------- <br /> Application is hereby made to the Son Joaquin Local Health District for a per 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 /> '-" " µ -CENSUS TRACT ---------------------•_- <br /> -- <br /> JOB ADDRESS/LOC TION ------ ��--'- --------- <br /> Owner's <br /> -------Owner's Name c'_,_A ----VS s-.E>j-_s ------------------------------------>------------------.Phone ---------------- ------------------- <br /> --- .- ---- f <br /> r -- �� '(tel <br /> Address ---- - <br /> Contractor's Name ------ Phone <br /> `/6 <br /> Installation � - <br /> will serve: Residence �"Apartment House Commercial ❑Trailer Court ;❑ <br /> ! Motel ❑ Other---------�----------------------------------- <br /> Number of living units:------- ___ Number of bedrooms ---1_------Garbage Grinder,'/1)_-.__ Lot Size �___�{_ e__--------------------- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------- ------Private 1�' <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam V' 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 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size__------- ----------------------------------- Liquid Depth -------------------------- v <br /> Capacity ----- -------------- Type ----------------- Material---------------------- No. Compartments ---------------------- <br /> Distance <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 nearest: Well ------------------I------ Foundation ------------------------ Property Line -------------------_-- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ____ --________ Number Rock Filled Yes ❑ No.❑ <br /> Water Table Depth --------------------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------'----------------Foundation ----- -------------- Prop. Line ______-_..____-_-_.__. <br /> 5 <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -----------------------------R------------- Date :____-_________-------------------} <br /> r <br /> Septic Tank (Specify Requirements) ------------------------------ --------------------------------------------=-- -------------------- ----------------------------- <br /> Disposal Field {Specify Requirements) <br /> 1_ I .--a--- �/-� ' _ '' -`---------------------------------------------- <br /> - - ----- <br /> --------- <br /> [Draw existing and required addition <br /> -------- ------ -------------------- ----------------- <br /> =--- - <br /> -------------------------------------------------------------------- <br /> dition 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 fbe,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 become subject to Workman's Compensation laws of California." <br /> Signed _.._ --------------------------------- Owner <br /> BY - --- --------- ---------------------------------------------------------------` Title -------- ----------------------------------- <br /> (1f 0 •er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- � N1---.P- ---------------------------------------------- DATE __. ------ 7 ------- ---------- <br /> BUILDING PERMIT ISSUED --------------------------- - ------------DATE ------------------------------------------- <br /> - - - ----------------------------- <br /> ADDITIONALCOMMENTS ------------------------------ ---------------------------------------------------------------- - -----------------------------------------_---------------- <br /> ----------------------------------- -----------------------------------------I-------------------------------- ---------------------------------- --------------------------------------------- <br /> ------------ ----------------------- ---- ------------------- ------- <br /> Final Inspection by: ----------Vu- z k ( '� ----------------------------------------------------------------------Date 11 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M �/ <br />