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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..................................................... Permit No. ...7..��� /3 <br /> )Complete in Triplicate) ' <br />....................................................... <br /> Dote Issued ..�:. <br /> ..................I........___-_-••••••. This Permit Expires 'I Year From Date Issued <br /> ............ ' <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 ...__. ._. _._ ................... "CENSUS TIfACT .......:....:_.._.:.._:.:: <br /> Owner's Name (0 ...... . .. . . . ..... ..... .,.....................Phone [......................... <br /> Address ---a_.F-8..__.... .........-•------- <br /> 4 ..._.. •-•-.. City .. -----...... _ n�-_.._.... . .............................. <br /> Contractor's Name ..- .__....License #&14.4 <br /> ........ ..................... <br /> �.. Phone <br /> Installation will serve: ' Residence [�partmeiit House Commercial ❑Troller Court 0 <br /> Motel ❑Other .................................. <br /> Number of living unitr...__...1_._ Number of bedrooms : _....Garbage rinder ....... Lot Size ............................................ <br /> Private <br /> Water Supply: Public System and name ---------- - -- • •--- . . -------••................ ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ZCloy Loam ❑ <br /> Hardpan ❑ Adobe.E] Fill Material ............ If yes, type'.-..------------_------_- <br /> (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.J <br /> NEW INSTALLATION: (No septic tank or see age pit permitted if.public'sewer is available within 200 feet,J <br /> PACKAGE TREATMENT ( ] SEPTIC TANK'[ 5ize_.�_�X.l�._�a'..._5-.`.- ?-__.-..-:- Liquid Depth __! .................. <br /> Capacity _/60D_ Type �s.L.�.... Material.{ Na. Compartments+` .............. <br /> Distance to near t., Well ....__,..../" ...........Foundation ...../.JP ----- Prop. Line :.. ..... <br /> LEACHING LINE [l� No. of Lines _---.-. ------ Length of each line-----7;!57.1.............. Total Length ............ <br /> 'D' Box ----/..... Type Filter Material ....._-�.......Depth Filter Material _/ ....:.............................. <br /> Distance to nearest: Well ----- .__..:;;. Foundation .___ ........ Property Line :. ................ <br /> SEEPAGE PIT (. Depth ....a�4.....__. Diameter ... . ....... Number ::._____ ...______... Rock Filled Yes (� No ❑ <br /> Water Table Depth .............f•- ...............- .......Rock Size -- � .�._..� �..... t <br /> Distance to nearest: Well ................. .................Foundation .... Prop. Line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .......................... <br /> SepticTank (Specify Requirements) ----------------- --•-•--•------------------------• ---......_....-•----------.............................. •..._...---•-------... <br /> Disposal Field (Specify Requirements) ........................---•----------------._._.......-------------------------•--................. --------•---....._:.-:.... ------ <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 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 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's Compensation laws of California." <br /> Signed ....................................... •.... Owner._ .. <br /> BY u �._.- ... Title . 4 �!.................. ................. ...: <br /> ....................•-•- .- <br /> (If other than owner) , <br /> `FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. DATE ................ ......................... <br /> � <br /> BUILDINGPERMIT ISSUED ..........................................................................................................DATE -...--- ..:_.........._.................... <br /> ADDITIONALCOMMENTS ._......---•--.........-•................•----------•-----........._... ------....------................--•------------...............----•---•---.......------ <br /> ..-•........................................ • :.....--- - ----------------------•--•-•----- -------------------------------- ------------_...............------......-•-••••. •--.... <br /> ........................................ .. ....__ a j .. <br /> • . �, <br /> Final Inspection by: Date <br /> SAN JOAQUIN LLOCAL HEALTH DISTRICT <br /> 7/723M <br />