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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> .......----•--1111....................... Permit No. <br /> lComplete In Triplicate) ... .............. <br /> _ _ _._ . . ....._.. ..... <br /> ---- -- -�.......:..................1111------1111.----•• . `-/`J-- <br /> . This Permit Expires I Your From Date Issued Date Issued ................... <br /> Application is hereb made t the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> describ . This a ication de in compliance with County Ordinance N549 and exisOng Rules and Regulations: <br /> JOB DDRES L C T10N �� �ENSUSRACT <br /> ......... ..... ........... <br /> Owner's Name✓c�� .. --...................................... ...........C...:.........,......Phone ..... ..1 1.1.1.................._.. <br /> Address . . ... ... /��aD City�i� ' -��- <br /> .---�... ---•-- <br /> r......... ............. .................... <br /> ...........-1111. <br /> _1111. <br /> Contractor's Name .. ................................................License Phone 1111-.................. ...... <br /> Installation will serve: Residence❑Apartment House Commercial❑Troller Court <br /> Motel ❑Other ............................................ <br /> �. <br /> Number of living units:... _._.. Number of bedrooms _'I------- Grinder ............ Lot Size ....._.•..................................�' <br /> Water Supply:,Public System and name ............................................................................................._.. ....... <br /> 1111.Private <br /> Character of soil to o depth of 3 feet: Sand b Silt❑ Gay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe [I 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 .......................... <br /> Capacity -------------------- Type .................... Material.........---------__ No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...........-.......... Prop. Line ...................... <br /> LEACHING LINE [ } No. of Lines ........................ Length of each line............................. 'Total Length ............................ <br /> 'D' Sox .... ....... Type Filter Material ....................Depth filter Material ............................................ <br /> Distance to nearest: Well _....................... 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 /> REPAIR/ADDITION{Prey. Sanitation Permit# --------.--------------------------_------ Date ..................................I <br /> Septic Tank (Specify Requirements) -------..................................---------...• -•------ -----• .................._.......1.......11 ......... <br /> Disposal Field (SpecifyRequirements) ` -a___-_ n ---....... �.........................1111•-_-_-. <br /> !f� � .. . ........-?,6`X.-�-r�............................. <br /> ........................----------------------------------------------------------------------------------....-._..•---•.............................................................................. <br /> 1111 <br /> {Draw existing and required addition on reverse side) <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: <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 -------------------------- <br /> --------------- Owner <br /> By ------------------------------------------- � -......-- --�-- Title _ -d? :._.. <br /> (if other than awned --- .. 1111..------ 1111------------ --- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _......-- -_ DATE .....L-1T .._.._..._ <br /> ------ <br /> BUILDfNGPERMIT ISSUED - ---_.........................•--------....._......_ _.............................DATE ........................... ........ <br /> ADDITIONAL COMMENTS -----L....... ............. - <br /> --------------• -------------•-• ---------------•-- ------------------•---•------------•-•----••-•------------ ...---•---- ......----._._...---...........-----....... .--......................................... <br /> ._-_11. --- - - ------- ------------•- <br /> - <br /> ..----•------111__1----- ----------- --------­---------------------�--..._ <br /> Final Inspection by: _.-1111 -- ----••-- --•-- ... Date , .� ,�....._.----- <br /> Efl 13 2h 1-68 Rev' 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />