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4 FOR OFFICE USE: ' <br /> i .4 APPLICATION FOR SANITATION PERMIT <br />.. ........ ..................._........ ......... ....... 3� 9 <br /> (Complete in Triplicate) Permit No. ..T.�"......:.:.... <br /> I.......... ........................�:.,y�_....__. �"-� �3 <br /> This Permit Expires i Year From Date 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 C&Aty'Oi'dinpnce No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ... /_ _---_---- . `:U�:.............................:...............CENSUS TRACT ............._............ <br /> Owner's Name .............................................................. ......................Phone . <br /> Address _.................�`------ �` ...................I City ��`► ..... <br /> Contractor's Name ...License #`tel-�` Phone // .. <br /> Installation will serve: Residence partment Houses] CommercialTtDTrailer Court , <br /> ,Motel []Other ........................................ i <br /> Number.of living units ..... Number o rooms _ ....._Garbage Grinder".- ------ Lot Size ............. <br /> t - <br /> Water Supply: Public System and name ......:. - __-.-:--- !��..... `. .....__._._•-•.........................Private ❑ <br /> Character of soil to a depth of 3 feet: ..Sando, 4ilto clay ❑ Peat❑ Sand Loom ❑ ClaY Loam <br /> ❑ <br /> Hardpan ❑ Adobe Material ... If yes,type ---------------------------- <br /> (Plot plan, showing size oflot, 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-,.........:­...... ...................I- Liquid Depth _..,_. .................... <br /> I <br /> Ca at it <br /> P Y.• :­:-'-Type ... Material------------------_--_ No. Compartments ---------_-.•-- <br /> `�.. ._. <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 ........................ Foundation ........................ Property Line :....................... <br /> t <br /> SEEPAGE PIT [ i Depth .........:.......... Diameter. ................ Number ............................ Rock Filled Yes ❑ No (:I <br /> Water Table. Depth —_—..._—..--=-=_Rock•.Size...:....:......... <br /> Distance to nearest: Well ........................ --------------Foundation .................... Prop. Line ................... <br /> i / (Prev. ;'- ------ Date ..................................I <br /> REPAIR/ADDITION PSanitation Permit #•--•-•------------------------------ <br /> 1 <br /> Septic Tank (Specify Requirements( ......-......:....... ............................ <br /> Disposal Field (Specify Requirements) .......... - ...__---- . _- _ `"------_- .-- -``f el <br /> �l , <br /> Y `------- <br /> ------------------•-------------------- ------------- ..... <br /> ------------­---- _ ...._.. ............ •------ --------------- ----------------------------- <br /> reverse-side) <br /> (Draw existing and required addition on ree}" <br /> I hereby certify that;1 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: 1 <br /> "I certify that in the performance of the'work for which this pertnit is issued, i shall not employ any person in such manner <br /> as to become subject to Workman's1CompensaF(on laws of California." <br /> Signed . i -.__._F-_•-- --•--- . Owner <br /> I <br /> Title <br /> (If other nerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... ATE <br /> .........---•-•---- —�.. .....,_.. <br /> BUILDING PERMIT ISSUED ..:......:....:.. - ..... ..DATE .::.....:...... <br /> ADDITIONAL COMMENTS ............................... .aiia---------.-.--------;. <br /> S <br /> 1 ........................................... ...... ! ,..e ............._........ .... ..........__.._._..........._..._._......._........................._......._.....-_ l <br /> ....... ......................... - <br /> ......................................... ..._ <br /> Final Inspection by: l^r Date ....��.. ..... <br /> HEALTH DISTRICT <br /> F w 13 24 t.-AA Paw $;AA 7172 3 M <br />