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FOP, OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No� <br /> ------- -------------- (Complete in Triplicate) <br /> ----------------------- --------- ----------- <br /> -- <br /> ---------- Date Issued _---------------_ <br /> ---------- This Permit Expires 1 Year From 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 /> JOB ADDRESS/LOCATIO ------ Z------------ --------------CENSUS TRACT- --------------w----------- <br /> 1 ::77 1/.;�J-�;r <br /> Owner's Name ---- --------------------------- -Phone ----- <br /> -----Z---- ----------------------------------------- <br /> Address -----VO ------ - ------ - -------- ------------ city _­S� k� <br /> Contractor's Name <br /> --------License Phone <br /> --------- <br /> Installation will serve: Residence grApartment House,E] Comrnercial :E]Trailer.Court <br /> Motel [7] Other ------------ -- ---------------------------- <br /> Number of living units:--------- -- Number of bedrooms .,_3..-.Garbage Grinder --------- Lot Size ��_61-13-4!0----------- <br /> Water Supply- Public System and name ------------------------------------------- -------------------------------------------------------------------Private <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand'El Silt E-] Clay El Peat E] Sandy Loam -El Clay Loam 0 <br /> Hardpan E] 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 TANK f I Size-----------------------------------•------------ Liquid Depth --------------------------- <br /> ---------------------- No. Compartments --------- ------------ <br /> CapacitY -------------------- Type -------------------- Material <br /> Distance to nearest: Well ------------------------------------Foundation -----------------------Prop. Line --------- -------------00 <br /> LEACHING LINE No. of Lines ------------------------ Length of each line---------------------------- Total Length ---------------.------------ ID <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------_1------ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -..---------------.----= <br /> SEEPAGE PIT Depth ------ No 0 <br /> --------- ---- Diameter ---------------- Number ------ --- ----------------- Rock Filled Yes [3 < <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> R) <br /> Distance to nearest: Well -------,--------------------------------Foundation ---------------•---- Prop. Line -------- -----­----- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# ------- ------ -------- ----------------- Date ------------ <br /> ------------ <br /> Septic Tank.(Specify Requirements) ------ ------ ------------------------------ <br /> Disposal Field (Specify Requirements) <br /> ------------------------------------------------------------------------------------ ------------------------------------------------ <br /> V.- ------- --------------------------------------- ------------------- - <br /> ----------------------- -------------------------------------------------------------------------------------------------------------- <br /> -- --------------------------------------- <br /> -------------------------- ----------------------I--------------------------------------------------------- ------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 11' 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 /> ted agents signature certifies the following: <br /> 'ill certify that in the perf6rmance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to becom sub* ct ytoYorkman'sCompensat' �laws of Cal <br /> ifornia." <br /> Sig _ <br /> By ------------------------------------------------------- -------------- ----------------------------- Title ------------------- ----------- -------- - -------------------- ------- <br /> ii (If other than owner) <br /> EPARTMENT USE ONLY <br /> TE <br /> APPLICATION ACCEPTED B ---- ------- DAFTE _ <br /> T <br /> BUILDING PERMIT ISSUED - --- ------------ --------------------------- ------------------- -----------DATE ... .... <br /> ----------- <br /> ADDITIONAL COMMENTS --- - --- ---- ---- -- ---- --------------------------------- ----------------------------------------- - -- ---------------------- <br /> ------------I------------------------------- - - - - ---------------- ------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------I------------------------------------------- <br /> ------------ ------------------------------- ---- --------- ------------------ <br /> ------------------------------------------ -------- --- ------- -------------------------------------------- --------------------- -----------i <br /> FinalInspection by; ---- - --------- --- - - - - --------- ----- ---------------------------------------------------------------Date <br /> A N AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />