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FGR OFFECE USE: <br /> PPLICATION FOR SANITATION PER'S yy_ <br /> -- - -- =------- -- - - r Permit No.4p__ <br /> (Complete in Triplicate# <br /> ---------=---------------------------------------------- J� /� <br /> _________________-___---____.-.___________.____________ This Permit Expires ] Year From Date Issued <br /> 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 1th County Ordinanc No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT N .-- --7 .__- 7 - -•------- -------CENSUS TRACT -------------- ----------- <br /> Owner's <br /> Owner's Name ---- -------Phone --------------------------•----- <br /> Address ---��_ __ _.....��_ city - <br /> Contractor's Name - T-- +----------------------------------- ----------License # ------- -:-------------- Phone -----------------•-_-------- <br /> Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other -------------- ---------------------------- _—X <br /> Number of living units:------- Number of bedrooms ________Garbage Grinder 6A--- Lot Size. _��__�__�� 0_____ _ <br /> Water Supply: Public System and name ------------------------ ---- •------------------------------------ ---------------------------------Private [ . <br /> Character of soil to a depth of 3 feet: Sand❑ Silt fl Clay .❑ Peat❑ Sandy Loam •❑ Clay Loam.p� <br /> Hardpan ❑ 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,) V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size___! �___X_-Y.A--4- 11" Liquid .Depth ------_____--.....-. <br /> �ae9 Q�No. Compartments ---------------------- ,1 <br /> Capacity -----____--���-,,-- Type __ ��_ Material- __ -- 2- <br /> Distance to nearest: Well _t G__t__---- ____ __.Prop. Line , ______F_-____. <br /> LEACHING LINE [ ] No. of Lines ---Z-________________ Length of each line__- ___9-a____ Total Length ­/677�......... <br /> 'D' Box k--0J__ Type Filter Material _T-e4t------Depth Filter Material .................................. <br /> r r � f <br /> Distance to nearest: Well _ dQ___7�_______ Foundation __/a__J�__-______ Property Line _ _____�____-:.__ <br /> SEEPAGE PIT [ j Depth -_� _________ Diameter x_( Number ----2-_________________ Rock Filled Yes !g—No .i[] <br /> Water Table Depth --------------------------------------- -- -----Rock Size ----- ----_------------------ <br /> Distance to nearest: Well ----------------------------------------Foundation --------------- ---- Prop. Line ----------------- <br /> REPAIR/ADDITION(Prev.(Prev. Sanitation Permit# ..-_--.. ----------------------------------- Date __-------------------------------_) <br /> Septic Tank (Specify Requirements) ----------------------------------- ---------------------------------------------- ------------------------------ <br /> DisposalField (Specify Requirements) ------------ ----------------------------------------------------------- <br /> --------------------------------------------------------------=----------------------------•----- -•--------•--•-:-------------------------•-------------------------------------------------------------- <br /> -------------------------------------------- R <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 r cin's C 1h6nsatton aws of California. <br /> Signed ---------------------- ----------------- ----- -- ------------------------------ Owner <br /> BY ---------------------------------------------------------------'--------- ------•••------------------- Title ----------------------------------------- - - <br /> (Ef other than owner) <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY � - --------------------------------------------- DATE " ��-� �-------------- <br /> BUILDING PERMIT ISSUED -------------- ---------------------------------------------DATE ------------ ------------------- <br /> --------------- <br /> ADDITIONAL COMMENTS ------- ----- - ----- ----------------- --------------------------- <br /> ---------------------------------- ------------------------•----------------------------'---------------------------------------------------------------------•---••-------------------------------------- <br /> f. <br /> -------------------------------------------------------------- -------- - ---_ <br /> -- - - -- ---------- <br /> ---------- ------------------------------------------------------------------------------ ---------- <br /> -------•--------------------------------------------- <br /> Final Inspection by: ------------------------------------------------------------Date <br /> --•• ----- <br /> SA-NJOAQ <br /> IN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> i <br />