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R OFFICE USE: APPLICATION FOR SANITATION PERMIT ' <br /> 7,57--4//Z) <br /> Permit,No. ..................... <br /> (Complete In TriplicatO <br /> ............. • ............ ....................... 73 <br /> I .... ........ <br /> .......................................... This Permit Expires I Year From bate Issued . ? . <br /> ts work' herein <br /> Application is hereby made to the.Son Joaquin Local Health District for a permit to construct and install th <br /> described. This application is inadiin compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ............. <br /> JOB ADDRESS/LOCATION ---------- ..... . ......................CENSUS TRAGI ............. <br /> _1--- --- <br /> .......................... .... 6 <br /> Owner's Name Phone . 4;�3......... <br /> Address <br /> 46 ........................ <br /> city <br /> Contractor's Name .••......... .....................License # Phone <br /> Installation will serve:. Re i sidence C)Apartment House 0 Commercial oTraller Gmo* <br /> Motel E]Other .................. ........... ...... <br /> Number of living units:_----- .... Number of bedrooms _.....Garbage Grinder ........... Lot Size ............................................ <br /> Water Supply: Public System and name ............. ...... ....................... ............ <br /> Character of soil to a depth of 3 feet ......................•.............................Private <br /> 11: Sand 0 Silt 0 E]Clay peat 0 Sandy Loom 0 Cloy Loom 0 <br /> Hardpan 0 Adobe 0 fill M6terial ... ........ If yes,type ............... ..........- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse sl e. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j <br /> i 1/, -54, <br /> PACKAGE TREATMENT SEPTIC TANK{ ILiquid Depth <br /> ... ......... <br /> ........ ........ <br /> Capacity ---- Type le <br /> ;Amateriol.... ------------__ No. Compartments ....ZZ............ <br /> Distance.to nearest: Well Z_4�� ................—Foundation ...................... Prop. Line ....... <br /> LEACHING. LINE No. of Lines ...A------•-. ----- Length of each line----- -------- Total Length ...... <br /> 'D' Box .../...... Type Filter Material /!4�Depth filter Material <br /> ... <br /> .................. ........... <br /> Distance to nearest: Well ....... Foundation ............... Property Line ..:�........... <br /> SEEPAGE PIT Depth -------------------- Diameter .............__ Number ............................ Rock Filled Yes 0 No C31 <br /> Water Table Depth ------------------------------------------------Rock Size -----_---- ---------- ....... <br /> Distance to nearest- Well ................... ....................Foundation --------_-_7------- Prop. Line ...... ...... ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...... ............._------------------_-- Date ____._..----•--•-••-......------A <br /> ....................... <br /> Septic Tank ;Specify Requirements[.--------------•-..._. ..... .................................I....... .................... <br /> I <br /> i Disposal Field (Specify Requie6ments) ---------- ­­...... .................. --------------­....... ---­-------- ................................................ <br /> ------------- --------I----------- <br /> ------------------------------------- ---­----------------------­................­------------ ...............1......_. <br /> -------------------- <br /> ----------------1----------m------------­-------- --------­------------ - ............................................. _-----------­-- ....... .......... <br /> I (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 /> C6unty 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 performanceofthe work for which this permit is issued, I shall 'not employ any person In such manner <br /> as to become subject P Workm::n�'s,�Cpensafion laws of California." <br /> Owner <br /> .......... <br /> .......................... <br /> Signed ..... - ----- <br /> By --------------------- ------- -----------_-------- ------------­- Title --- --- •------------------ ---------------------I <br /> 11f other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------- -------------- - ------------------ D AT E_.A; .7.5........ <br /> BUILDING PERMIT ISSUED --------------------------------------—.........I----------------- - DATE <br /> .... <br /> ADDITIONALCOMMENTS ... --------------- ---_------------------- ...................... ---------------------------------- -------- ------•-----------•.... _----_-----_ <br /> ------- <br /> -----------------------------------11 ------------------- ---------------- ---------------I-------------- .................. -------------- -- ..................... <br /> ------------------------------------------------- -------- <br /> -------------------- ----------- .....I.........***-------------------------------*----------- <br /> Final Inspection by. .................... ........ ........Date .... ......... <br /> .................•--•-------•..........----......------ ---------- ...... <br /> ----------------------------------I---------------0- .............I................. ................ <br /> ER 13 24 1-68 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />