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FOR <br /> OFFS USE:�- APPLICATION FOR SANITATION PERMIT ' <br /> . ............. .....r:..............�H. (Complete in Triplicate). . /�+j,� .�/ Permit No. .76...... <br /> 7 <br /> f/�6 � <br /> ...............:f_................................ ... This Permit Expires 1 Year From Data Issued <br /> ... .. ..... ............... <br /> Application is hereby rade to the San Joaquin Local Health District for a permlt to construd and install the work herein <br /> described. This application Is mader In compliance with Cau ty Ordinance No. 549 and existing Rules and Regulatlons: <br /> JOB ADDRESSAOCATION'. �/�� ............... .... :...............................CENSUS TRAGI ......................... <br /> Owner's Name l .._ .. . , ....................... .......................................Phone <br /> Address . _ .�. .... ..�J...... . ........ . ....................City .....? _ ..... . . .... <br /> Contractor's Name .— r.- ___...- :....... .................License # 1AP_1 Phone <br /> Installation will serve: dente Apartment Hauto0 Commercial QTraifer Court Q <br /> Motel.Q Other_..._........................... <br /> t Number of living units:_. '' ------ Number of bedrooms '5------Garbage Grinder ------------ Lot Size .-_-....................................... <br /> Water Supply: Public System and dame g -------------- <br /> ..............................Private <br /> Character of soil to a depth of 3 feet: Sand Q Silt 0.:. Clay Q Peat Q Sandy Loam Q Clay Loam❑ <br /> Hardpan❑ 'Adobe 0 Fill Material ............ If yes,type............... ............ (f <br /> ]Plot plan, showing size of lot, location of system'inrelation to wells, buildings, etc. must be placed on reverse side.] ! <br /> j <br /> NEW INSTALLATION: (No septic tank or.,seepoge-`Pit,permitted If:public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT ( ] SEPTIC TAN••KJ�-)�,.. Size..........................................:..... Liquid Depth <br /> 1 Copaelty/.,�1�TANK <br /> -- Materlal--••.................. No. Compartments .. ......�.-� <br /> Distance to neeea��rest: Well ---/ �.�...................Foundation ...._____. ........... Prop. Line .... .. .. <br /> LEACHING LINE { ] No. of Lines .�1.................... Length of each fine-7e ................... Total Length .�.................... <br /> } 'D' Box .--j__----- Type Filter Material .i ' ... <br /> Depth Filter Material ..� ..1.......................... <br /> .. <br /> Distance to nearesh Well _---------_-----_.-- Foundation ........................ Property Line ...................».. <br /> SEEPAGE PIT [ ] Depth .................... Diameter ................ Number ...-_....._................_ Rack Filled Yes Q Na <br /> Water Table Depth ......Rock Size ........... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...........-.........: <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .._-• .. <br /> -------------------- .........-----. Date ............. ......._..._... ] <br /> Septic Tank (Specify Requirements! ......................................... .............-- . -.................................... ........ ...._................ <br /> Disposal field ISpecify, Requirements) ...............................................................•--._................................................_.....I.......... <br /> -------•-•--•--------------••-------. -!.....................----....._......-- •-•--....................._...__.................._...............-••-........_..................................._ <br /> ......... <br /> .............................. •--..._•----- •----•------.............. -•--• . ........................... ........................................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 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. Hence owner or Been. <br /> t ; sed agents signature Certifies the following: <br /> "1 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 becomg s Co <br /> est toorkman sub Compensation laws of California."( p <br /> Signed ... _..�:.. ......................_....------....----•----........_.. Owner . <br /> r/ . . . . <br /> By ....:...................••-•-�----�---........................_...__.....---------------------------. Title ....................................................................... <br /> (lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-1-BY ... f.._. . _ ._ DATE .....r�'/ .:.............: <br /> BUILDING PERMIT ISSUED DATE <br /> ........_.__... <br /> .............................--•-_.... <br /> ADDITIONAtCOMMENTS ...........................---------------------------------..............----------------.................................................................... <br /> ' .......................................................•------...._...._....------....----........__.........._...-•-----...--•....._................... ...._................................. <br /> ......................................................................................................_..-.........................._ . <br /> .................................... ............................................................................ <br /> ._ ............. _ <br /> Final Inspection by: .........:................... '. .....Date ". ................. <br /> EH 13 2!t 1-68 Rov. 5N SAN JOAQUIN LOCAL HEALTH 8/711 3M <br />