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FOR OFFICE USE: <br /> APPLICATjON FOR SANITATION PERMIT <br /> ............................................... <br /> (Complete in Triplicate) Permit.No. <br /> ..........­...... ............. <br /> .....------•---.._................. ...................... . This Permit Expires ] Year Front 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 County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LO TION <br /> ......... ............ ...CENSUS TRACT -............... ......... <br /> Owner's Name ... ... 4-,Pc� <br /> ----­----4....... ......... ........Phone ........... ..................... <br /> . ... <br /> Address ----- - ......... ...... .. Ch .................. ......... <br /> ..................... <br /> Contractor's Nam --- Phone ....... ............... <br /> ... ... ...... -- ------- -- . . .......t.......License # <br /> Installation will serve: ,Residen Apartment House 0 Commercial OTroller Court 0 <br /> Motel E]Other ------- ...........*............... ......... <br /> Number of living units:---..-'./--- Number of bedrooms __3....Garbage Grinder ............ Lot Size ............ ............... <br /> ............. <br /> WaterSupply: Public System and name ....... ........................... <br /> .............__............................... .................Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 <br /> 9 C14 E] Peat[3 Sandy Loam UR/ Clay Loam 0 <br /> Hardpan E] Adobe 0 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 feet,) <br /> If public sewer Is available within 200 feet <br /> PACKAGE TREATMENT f J SEPTIC TANK Size.................................11............I Liquid Depth ........... <br /> i6 ............... <br /> Ccipacit�x__---------m.-­Type-------_.__---- Material...................... No. Compartments ..................... <br /> Distanceito nearest: Well ....................................Foundation ...... ............... Prop. Line _._-_..._............V, <br /> LEACH1114G LINE No. of Lines ---------_------- Length of[each line... .............. ......... Total Length ..... ...................... <br /> V Box ------------ Tyl�I'Filtei. .Material ... ...............Depth Filter Material ............... ......................Z <br /> i 41 <br /> Distancel3to nearest: Well ....... -------- Foundation ................ ....... Property Line <br /> .................... <br /> SEEPAGE PIT { ) ` Depth t ----------- ------ <br /> -Diameter-,�...........L Number ............................ Rock Filled' Yes 0 No <br /> Water Table Depth .........%---------1-4----------i'..............Rock Size ........... <br /> -------------*------- <br /> .-Distance to nearest; Well L..........4- ........... --------Foundation .................... Prop. Line ...... ............... <br /> REPAIR 'ADDITION(Preva Sanitation Permit Dote ---•--. ....... - ---------------- <br /> Septic Tank (Specify' Requirements) --_------­------------------ <br /> .............. <br /> ----------------- ............................... <br /> DISDOSOI field (Specify Requireirrien <br /> -- - ---------- . ................... <br /> --------------------_- ............................... ...................... ....................................I...... <br /> ................... ----------------- <br /> --------- ---------- -----------------------------------------............ <br /> -------------------------------------------------I....................... <br /> .1 (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepu'red this application and that the work will be done In accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son 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' Compensation laws of California." <br /> Signed --- ------------------ <br /> --------- -- ----- - ----10--- ----- ----- ----_---_--- Owner <br /> By ----------_- - VJ <br /> a� ----- ------ ...... ------------ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- <br /> -------- ----- - DATE <br /> ---------- ------------------------------------------------- ------ 3 <br /> BUILDING' PERMIT ISSUED . , --7, <br /> --- ----------------------------**------------*----------------------------------------DATE ......... --------------- ................ <br /> ADDITIONAL COMMENTS ------------------- -- <br /> -------------_1------­----------------__-------------- -- ------------------- ----------- ............ <br /> .................. <br /> 2 ............... ------­­.......................... <br /> -------------------------- ------ ------------I---------------- --------------- •-----.-• -------------------------­------------------------ -------- ---------- ............ ......................... <br /> ---------------- <br /> ------I............................ - ........ -- - <br /> Final Inspection by. ----------------­---------I------- -----*11------------- <br /> ate <br /> ...................... .....-----......------ <br /> ... <br /> EH 13 2h 1-68 • 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />