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FOR OFFICE USE: p L, / `7`--5 <br /> APPLICATION FOR SANITATION PERMIT <br /> ........................................._........_.•... Permit No. � <br /> (Complete in Triplicate) �- <br /> :............... T._ _._ ._ _ . . . . �. . .4.�_. . _� _ .. �.. ... �._.._.._.._. ..._._..._._ ._ <br /> _... �. <br /> - -�S 77 <br /> This Permit Expires 1 Year From Date Issued Date issued .�'.........:••• <br /> Application is hereby made to the Son 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 /> I .JOB ADDRESS/LOCATION. 6fl1Q g�� .._, .....................CENSUS TRACT .......................... <br /> k � o <br /> Owner's Name ...._ .....Phone <br /> ......................... <br /> Address . . . . ....... ..`7" y. .:.. .._........... _ ......... City . ...................:..............................__..._. <br /> Contractor's Name _...__. C --- - �!�-:...._.License i4t �---- Phone . <br /> _ G .......................:..... <br /> . .............. . <br /> i installation will serve: Residence[!rApartment'House0 Commercial flTrailer Court C] <br /> Motel 0 Other............................................ <br /> f / � <br /> C Number of living units:............ Number of�bedrooms ."... ..Garbage Grinder ............ Lot Size. _....••...•.....Qc'�=�- <br /> l _ <br /> Water Supply: Public System and name ....:....... -..:............:..::....� .......................-....:Private ®� <br /> Character of soil to a depth of 3 feet: Sand❑ /Silt)] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> HardpanAdobe fl 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' ublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size -••-----.... Liquid Depth ....T.................. <br /> 'k Capacity /5k_;0-_----- Type F Material•---p� <br /> No. Compartments ...............•. <br /> Distance. to nearest: WelI � - Prop. Line . ^i� <br /> ----------------- -- Foundation ...�..._ ... ..,.... <br /> LEACHING LINE (r�]� No. of tines __3............... Lengthy of each line... U..� --...-.-.. Total Length ...lkP <br /> i 'D' Box -:--- Type Filter Material ....;;FA_...._.Depth Filter Material ...f. ..° .............................. 1� <br /> Distance to nearest:-Well ...../eIrl"A....'Foundation ._../�'. . . �� ••• <br /> ._.. Property Line ........�...---- N <br /> SEEPAGE PIT Depth ---- .471 • Diameter :_ S _.4__ Number ------------ :--_-- Rock Filled Yes Ca-�' No i❑ V <br /> Water Table Depth --------- P/-- - - -- -------------Rock Size ..1. ..' .......... <br /> ..Foundation ._....1>p Prop. Llne .... .- ... <br /> Distance to nearest: Well ------- ......... �---... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------.----=.--------- ------ Date --•-------:.....................A <br /> SepticTank (Specify Requirements)................... ......___...............................................................................:.......................... <br /> t Disposal Field i5peci#y Requirements) .....:.......• - ---....---;•---......_......................---.----...---..........,...-.------............................ <br /> ---------••---.....---•-------------------------------•---- <br /> -• -•- <br /> •----- -- --•- ----•-- ------------ -----•----•..........--••-----•••-------•------•-••.................................................... <br /> {Draw existing and required addition on reverse side) <br /> 1 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 Heallth:.Dlstrid. Home owner or Itcen- <br /> I sed agents signature certifies the following: <br /> "I certify that in the performance of the.work far"which this permit Is Issued, I shall not employ any person In such manner <br /> as to become subject to Workm 's Compensation laws of California." <br /> Signed ---•- ---•---------------------- - -- --- •--,----- _... ............ Owner <br /> By -------- ----------- -- •4 c Title .: .--.---.......__.._. <br /> lif other than owner) <br /> FAIR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY •--- _ = -•-- --_a_e ------------------------_-- <br /> BUILDING PERMIT"ISSUED ....... ------------------•----•--••-• _/................... - --.-...-..__...- •--•----DATE - ....---------------. ---._.-....- <br /> ADDITIONAL COMMENTS -------------------------------------------- ----------------------------------•--•-------------- --------•---- ----------...._..... <br /> 4.. .•-.-.----------------------------- ------•--••-----------•-------._..---:---.-.-....__....------------------------_....._--------------•-----•-- ----._ <br /> -------------------------------- <br /> - <br /> .._-------•..............- --• ...._..........-. <br /> final Inspection b ..............Date -f. .Z.,. <br /> ` 3 .2lt 1-68 Aev. 5'M SAN JOAQUIN LOCAL HEALTH DISTRICT 8�7 3M <br /> F' t <br /> y <br />