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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ......................: Permit No. 7 7`_ 1.3 <br /> {Complete In Triplicate) -- ................ <br /> ....................................................... <br /> .... This Permit Expires f Year from Date Issued Date Issued . ............. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construed and install the work herein <br /> described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulationse <br /> JOB ADDRESS/LOCATI ' <br /> �... ..__......._ ..... f.1. E1. .. g CENSUS TRACT •--------•,......... <br /> Owner's Name ...�C ! = <br /> G ....................Phone .................. --••-•-•------•-- <br /> Address ..........�.�.g- �'� . ... - ...City ....... ................................................... <br /> _ ,�-- - - .... .... .... .... caense .. S _ Phone ---_- _ -------- ----------- <br /> Contractor's Name <br /> Installation will serve: Residence❑Apartment House❑ Commercial❑Trailer Court ❑ <br /> Motel Q Other__.............. ............ <br /> Number of living units:... Number of bedrooms _ Garbage Grinder Lot Size ^ <br /> Water Supply: Public System and name .............Private[sj� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan❑ Adobe❑ Fill Materlal ............ 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 feast,) <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.....................I...... Total Length � <br /> D' Box Type Filter Material .,_--Depth Filter Material p <br /> Distance to nearest: Well .............. ... Foundation ................. ...... Property Line ........................ S <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(Prev. Sanitation Permit# ............................................ Date ............. ................ <br /> Septic Tank (Specify Requirements) --•---...------•••....................•-••-----•--............_........•---.............•----....._.....__._._...--•-------•-•---.........of <br /> Disposal Field (Specify R q irem nts) •--•-••-�•--•--•---'-------------••------•-•-••••....-•••----.........-••--....... _./ X <br /> .. . - � .. . ............ ...................... s <br /> t <br /> -•- - ---. . <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 don* In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health;District. Hunte owner or !leen- <br /> sed agents signature terrifies 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 sublet Workman's Compensation laws of California." <br /> Signed ---------------- ..-• Owner <br /> BY ..................... <br /> --- ••-----•----... title - <br /> (If other than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.-.. 71K# ------------------------------ DATE ..y-".L.�4�....��__._._....._: <br /> BUILDINGPERMIT ISSUED ------------------- -•... .......................-----------.............................DATE -----------------I......................... <br /> ADDITIONAL. COMMENTS -- _......... ..................................... <br /> ---------- -------------•- ....-. _. -• •-- ----------._._....-------. ------ ...----­------------------- . r�...... --._..._..._... <br /> FinalInspection by: _. .. :.. ---------------- ...................................................._.__...........__.._bate .. .- -..._ ....... . <br /> J 3 21a 1-68 Irv. M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7& 3M <br />