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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 7S 73z <br /> (Complete In Triplicate) Permit No. ..................... <br /> ................................................... This Perm It Expires I Year From Oat*Issued Dote Issued <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> describes]. Thi application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations, <br /> 7"" .e-4S71 n <br /> JOB ADDRESS/LOCATION ... .. ....f�.. .. ---------- .::...................CENSUS TRACT .......................... <br /> Owner's Name ................Phone <br /> Address ........... ---------------- .................................. City . G'A1 �✓ <br /> Contractor's Name ..jQ. ../��J � l�,----------.---------------------------------•.License .._._..._.---..........----•-- <br /> Installation will serve: Residence$Apartment House 0 Commercial OTrailer Court <br /> Mote! ❑Other -----------------------------••--•--•-•---•- <br /> Number of living units:-.-/------- Number of bedroomsA.......Garbage Grinder ----------.- Lot Size __________________ <br /> Water Supply: Public System and name -------------—......-A------------------------------------------_----••-• _-------• .....................Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan I[ 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 I ] Size------------------------------------------------ Liquid Depth -------------............. <br /> Capacity --- ---------------- Type -------•- •--------- Material----------------_--- No. Compartments <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... <br /> � <br /> LEACHING LINE ( ] No. of Lines -------------- ------ Length of each line------ --.___........--.-- Total Length ............................d <br /> 'D' Bax ............ :Type Filter Material -------------------Depth Filter Material ............................................ <br /> Distance to nearest: Well ..:.. ................... Foundation ----............------- Property Line ......_. .......... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter`"-`.............. Number ---------.---•---•--------_ Rock Filled Yes ❑ No I�] <br /> Water Table Depth . , <br /> ---=------....................------------------Rock Size ............................... <br /> Distance to nearest: Well-------------------------------fT:�--Foundation ------ ............. Prop. Line .... .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........................ ....._.------- Date ------------------................] � <br /> A <br /> Septic Tank (Specify Requirements) ------/ ...w ig.L-----J_�7-P�.................................................................•.. <br /> Disposal Field (Specify Requirements), <br /> ,4_4_ -------JA.---�y <br /> -------------------------------- --•-•---•-•---------- =---------------.-....-•----------------------------------------------------•-I •------•---------------------------- ........... ........... ' <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 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation California." <br /> Signed .. /�.i- � C'JGea ------------------------------------------- Owner <br /> By ---------•- ---- ----------------_-- --- ;------ ....------ ,.. Title ....- <br /> ------ --------------- -•-- <br /> (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---_. . . :.._ DATE .... ._... �` ` <br /> ----- <br /> BUILDING PERMIT ISSUE© ---------------------------------------------DATE ........................................... <br /> ADDITIONAL COMMENTS --------------------------------- <br /> - <br /> . ........... ----------------------------------- --••--------------------•------ --------- ---------------------•.._.............. -- ---....._._..........._....---..._..... <br /> ----- --------------- ------ _. ........ ......------- -- <br /> --Final inspection by; -------------- <br /> 13 1`6 v• A - - -------------------_--- ---- -•----_. ate:------------- <br /> EH <br /> 8 7 <br /> N JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />