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FOR OFFICE USE: <br /> APPLICATION ICORSANITATION PERMIT <br /> --------------- <br /> (Complete In Triplicate) Permit No. <br /> .................. <br /> . This Permit Expires t 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 wit County Ordinance No. 544 and existing Rules and Regulations, <br /> JOB ADDRESS/LO ON ../L ..._L../�... . .... ... .......� _,%.....................................CENSUS TRAGI' .......................... <br /> Owner's Name .. �- �....... �?rZ .-... . . .-..... Phone <br /> Address ...... ....... ..7..T....X..�1.��..�.�............._..City ' .R ........ ............... <br /> ...: -�- a J� Licensee . Phone . , <br /> Contractor's Name .._. _....... - -� ...__.�....... ..._......................... <br /> a <br /> Installation will serve: Residence"A rtment House E3 Commercial QTraller Court Q � <br /> Motel [)Other ..... ............................. w <br /> Number of living units:- .f -_--.. Number of bedrooms ;?:-„ .Garbage Grinder ............ Lot Size ..--G........... ... <br /> Water Supply. Public System and name ....-•.......................................... ,..._................... <br /> , ............ ....... .-Private <br /> \ . <br /> Character of soil too depth of 3 feet: Sandt3 Silt Q Clay Q Peat C3 Sancly Loarin lay loam [� <br /> Hardpan l-7 Adobe Q Fill M6terlal ............ If yps,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 newer is available within 200 feet,( <br /> PACKAGE TREATMENT j I SEPTlC TAMC j Size_...................... ........ ........ Liquid Depth ........._..........,,.__ <br /> Capacity ... --- Type -- - Ma <br /> ..................elcil- --•--- ---...... {�or Co partments <br /> Distance.to nearest: Well ---•----........................ ,houndatlan .................... Prop, Linn .................... <br /> . . . <br /> LEACHING LINE ( ] No. of Lines ....................._ Length of each litre............................ Total length ........................... <br /> 'D' Sox ...,..:..... Type Filter Material ....................Depth Filter Material ---..................................... <br /> Distance to nearests Well ........................ Foundation ......................._ Property Line ........................ <br /> SEEPAGE PIT { J Depth .................... Diameter ................ Number ............................ (tock Filled Yes Q No <br /> Water Table Depth ,.................................•----.._......Rials Size ................................ <br /> Distance to nearest: Well ..............Foundation ...... Prop. Line <br /> 4 PAIR/ADDITION(Prev. Sanitation Permit ............................................ Dago ..................................} .. .. <br /> Septic Tank {Specify Requirements} ....................... ,., ................... <br /> Disposal Field (Specify Requirements) � <br /> C <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 San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner or. Ilcen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this perMit is Issued, I shin# not employ oily p*rsap In such Mann” <br /> as to become subject to Workman's Compensation laws of Cttllfarnig," <br /> Signed --•----------=------------------------------------ ----------------------•-• --------------•-----.- Owner <br /> By ................. ..................................•-----------------------•- •------------- Title ----------------..... ------•---....._._...---•-•---- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ~v � "2� <br /> _ -_...------•----------------------------------------------•---.-------------------. DATE ...�. ....._....................----_.: <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------..... <br /> .........------......--..................... <br /> DATE .................................. <br /> ADDITIONAL COMMENTS ---------------- ---------. ------ <br /> ------- ------------------ ------------------------------------�--- <br /> --------------------------- <br /> --•--------------------------------- ............. <br /> --- <br /> -11-111-1 <br /> .................................. ............................Date .... ......... .� ..................Inspection by: . .. ------ ------ <br /> EH <br /> 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />