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FOR OFFICE USE: <br /> - ------------------- -----;------------- ---------------- APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------- (Complete in Triplicate) Permit No. <br /> ---------------------------------------_:----------I------ This Permit Expires I Year From Date Issued Date Issued <br /> Application is hereby made to the San Joalquin 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/LO ION, - ------------ <br /> T . . - --- - - ----------- --- ----------CENSUS TRACT <br /> Owner's Name & <br /> Address __4 - --------- ------------------------•----------_ ---------- ------------Phone ---------------------- ----------_- <br /> - ------- --- City -------------------------------- <br /> Coniractor's Name ---- ----------------- ---- ------- ---- --- - ----- --..,License # --- ------------------- Phone -- ---------------- <br /> - <br /> will serve. Residence Apartment House❑ Commercial f7railer`Court <br /> Motel F1 Other <br /> Number of living units:________-_ Number of bedrooms __-- Garbage Grinder _________ Lot Lot Size ---- —----- <br /> Water Supply: Public System and name <br /> Character of sail to a depth� - --------------- ---------Private <br /> of 3 feet. Sand [] Silt Clay E] Peat E] Sandy Loam Clay Loam,.0 <br /> Hardpan Ej Adobe Fill Material --- -------- I <br /> 4 ;If yes, type _______________--_ <br /> --------- <br /> 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 r j SEPTIC TANK'[ I <br /> Size <br /> - --------------------- Liquid Depth <br /> ------------------------ <br /> -�Cpp!q - if <br /> cit ---------------- - - - I <br /> Y� T9fyo ---------------------- Material-------- No. Compartmenti!, --- ------------ 6%� <br /> Distancelto nearest-. Well ------------ ----------------Foundation ---------------------- Pr I op. Line___...____:-.___-_-._-_. <br /> LEACHING LINE Noof Li I nes : <br /> ------------ Length of 'each line-----_------t-,------------- Total Length- ------------------------- <br /> 'D''Box <br /> ------------ Type Filter Material --- ----------Depth Filt&AMaterial ----------------- <br /> ------------ <br /> Distance to nearest- well ------------------- L <br /> Foundation ------------------------ Property Line <br /> - -------------- <br /> ------_- <br /> .SEEPAGE PIT Depth -------------------- Diameter ---------------- Number ------ ------------ Rock Filled Yes ❑ No <br /> Water Table Depth ------ <br /> ----Rock Size <br /> -------- <br /> 4------------------------ <br /> Distance to nearest. Well -------------------------------- ...Foundation ------ <br /> REPAIR/ADDlilON(Prev. Sanitation Permit# --------------- -------------- Prop. Lln4 ---------------------- <br /> -------------------------- Date ----------- <br /> Septic Tank�(Specify Requirements)---------------------------- <br /> ------------------------------------ ------------------------- ----------------- <br /> D' I Field (Specify-Req ------ <br /> uirerpen ---- ------ ----------------------------------------- <br /> --------------- --------------------------- ---------------------- <br /> �,4 <br /> -- ---- - ----- ----- a <br /> ---------- <br /> - - -------- ------ -- <br /> - -------------- ------------ ----------- <br /> --- ----- --- -- ----------- ------------------------------------------------ <br /> I------ ---red dit-i-o-n--o-n--reverse-side} <br /> ----------- <br /> _� and �uij ad <br /> (Draw_exist:;�� <br /> 'in <br /> I hereby certify that I have -prepared this application and that the work will be done in accordance'with'Son Joaquin <br /> County Ordinances, State Laws, and Rules and-Regulations of the Son Joaquin Local Health District. <br /> sed agents signature certifies the Following:' Home owner or licen- <br /> sed <br /> 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 beco <br /> 7MIg Ebjec�t to Workman's Compensation laws of California." <br /> Signed --- <br /> By ---------- -- ---- ---------- -- --- --------- ------------------------------------ Owner <br /> ------------- ---------- Title ----- <br /> ; other o�wvner <br /> _4 _ <br /> <: <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED Ell,I, <br /> BUILDING PERMIT ISSUED --- ------- DAtE?_-/--F--------9------------- ------ <br /> ADDITIONAL COMMENTS ----------------------------------- --------------------------------------------------------------------DATE --------A----------------------------------- <br /> ----- ------------------------------------- ------------------------------------------------L-------- <br /> ------------ ----------------------------------�&---------- ------------ -------------------------------------------------------------------------------------- -------------------------------------- <br /> - ---------------------------------- -- --- ----------------- --------------------------------------------------------------------------------------------------------I-------- <br /> ----------------- ----------------- <br /> FinalInspeciion y� -- - ----- ----- - ---- -------- L----------------------------------------------------------------- <br /> ----------- ------------------------------------------------------- -------------------------------Date-----�f- --------------4------- <br /> ---- ------ - ---- <br /> ---- ---- ----- - ---------------- <br /> X <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. ii <br />