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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ................................................. <br /> . s-�..--• <br /> (Complete In Triplicate) <br /> 9 7� <br /> - Date Issued ...6—......:.........• <br /> ................... . This:Permit Expires 1 Year From Date Issued <br /> } <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/LOCATION .. .. ......w. !.................... -...................CENSUS TRACT ...... ............... <br /> Owner's Name 9�--.. _.. <br /> N. .........................................: .................Phone .......................... <br /> Address . . 06, ... .......}z�.. City ... D- .....��'" ............................... ....... <br /> Contractor's Name . i /. .. Phone <br /> Installation will serve: Residence Apartmen ouse❑ Commercial ❑Trailer Court '❑ <br /> Motel ❑ <br /> Number of living units:_._)... Number of bedrooms Garbage Grinder ............ Lot Size ...... `. <br /> Water Supply Public System and name C . __....... _••.• •- Private [� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat 0' Sandy Loom 0 Clay loam ❑ <br /> Hardpan p Adobe [] 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 TALK{� Sizey��O- --1 -�-X--- ..(..-•---... Liquid Depth ...11................... <br /> Capacit�_O_o_ - Type . _/�- �'_ Material...� No. Compartments ....... .......0 <br /> Distance to ne est: Well ..._ Foundation .---- .Q .. Prop. Line .. ........ <br /> LEACHING LINE ( ] No. of Lines --------------- ........ Length of each line................--•......... Total Length ..........................or <br /> 'D' Box .... ------- Type Filter Material ....................Depth Filter Material ............................................ <br /> t <br /> Distance to nearest: Well ------------------------ Foundation ................... Property Line ....... ............... <br /> - Depth c ...`-.-.-_-_-. erNumber ....---- .................. <br /> Water. Table Depth ---------- ------ Ro. . _ <br /> i Distance to nearest: Well .......... .... ........ .... ......Foundation ....... Prop. Line <br /> REPAIR/ADDITION lPrev. Sanitation Permit# .......-....................................... Date .............................. e <br /> f Septic Tank (Specify Requirements) ---------- ---••--------------------------------------- ..............................•-------------_- ..................... ............... <br /> Disposal Field (Specify Requirements) .................. ------------------------------------------------ .................V <br /> - ---------------------------------•---•----------...-------•-------• . ------....... <br /> ------------•----------------------------=------------------- -------------------- <br /> --------------•------------------------------•--------------------------------• .....................----------• -•-- -- ----------- ......................................................... <br /> } (Draw existing and required addition on reverse side) <br /> 11 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> I County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner or liven, <br /> F sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is Issued, I shall notemploy any person in such manner, <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------- ----------- L.-------------- ------------------ Owner <br /> By ... . • .--- ,�.. ----- --------- Title --- .L u,. _---------------------------- <br /> (if other than owner) - <br /> I COR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTS© BY DATE .. ... ..v <br /> --------------•- - ----- - <br /> BUILDINGPERMIT ISSUED .--.----------- - -------------------------------------------- --------------------------------------DATE ---------------- ---.._...-----.-..._..._.. <br /> ADDITIONAL COMMENTS ---------------------------------- ­­...............-......... <br /> . <br /> ----------------------•----------•--------- ----------------- ----------------.............-................ ....................... <br /> ..---•-- ------- .- .. --- -------- -----`- -------------•------------------------------------ -----.-..------------ . --------------- <br /> . .. <br /> finalInspection by: . -t-----------------------------•--•--•--•-•-•••---............---..._..-•----.....Dote .. .�...._..._._... <br /> EH 13 .24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7)t 3M n- <br />