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rtr+C 4.Irrll,� L/Jrs <br /> APPLICAT;flN r-OR SANITATION PERMIT <br /> "" <br /> Permit No. <br /> (Complete In Triplicate) <br /> ................... This Permit Expires i Year From Date Issued Date Issued".:a. :� <br /> Application is hereby made to the San 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 /> J08 ADDRESS/LOC ON /T 7.... :.. � .. '......................CENSUS TRA <br /> C ....... <br /> .. .............. <br /> Owner's Name ... ..... .:........... �.................... ... .........................Phone ... .-......4 �J A�ep.. <br /> ��^^ <br /> Address .....V.... ... .:................:_ <br /> 1� .... city ..-. - ... . <br /> Contractor's Name .... �_... _.. - ............ .........License # ..... Phone <br /> Irl;tallotion will serve: Re dente partment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other................ ........................... <br /> Number of living units:............ Number of bedrooms .......Garbage.Grinder ............ Lot Size ............................................ <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 /> Hardpan❑ Adobe❑ Fill Mnterlal ............ 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 ] Size--..,,,,........................................ liquid Depth .............._........... <br /> Capacity rial...................... No. Compartments .... <br /> Distance to nearest: Well ....IA0-_!...............Foundation .-� .... _ ......._. Prop. Line . ... <br /> ....... <br /> LEACHING LINE [ ] No. of lines ..7................. Length of each Ilne..7 .�................ Total Length f�14L ........ <br /> D' box .`......._ Type Filter Material kz?` ..Depth Filter Material . sL�..... <br /> ............................. <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT ( ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No Q <br /> Water Table Depth ................................................Rock Size ----------•-----•-.------------- <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ........._........ <br /> _. <br /> REPAIR/ADDITION(Prov. Sanitation Permit# ............................................ Date ..................................) <br /> Septic Tank (Specify Requirements ...................................••-----.....--•---......-•----.—..........•..... <br /> Disposal Field (Specify Requirements) -...:=....:. <br /> ............................................................................... .......................................................................................................................... <br /> ...........-•-•-•-----------------•-.....--••--•-_.....----...--••••----......................-----•--•••--•-............. .....•---........... ........... <br /> ........... <br /> ........_.._... <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 toorkman' Compensation laws of California." <br /> nn <br /> Signed Lam . ........... Owner <br /> By ............................................................ .......................................... litre ......_.................I............................................... <br /> (If other than owner) <br /> FOR DE fARTMENT USE ONLY <br /> ....... DATE ... =../.1..... .. <br /> APPLICATION ACCEPTED BY .. ... —7; •r ... <br /> BUILDINGPERMIT ISSUED .................• -•-•---- ---•--................-•••-•--•--..........................................DATE .............................:.....a....... <br /> ADDITIONALCOMMENTS .................................................................._...............................................................I.................•--....:.: <br /> ....-•.................•--.......---.............------..............•..............................................................................................:................I.................... <br /> .............................•--........... <br /> .. ....................... ........... ._....•... ...._........... <br /> Final Inspection by: ....... ]�._ .............................................................Date ..f,yr.���..7�................ <br /> EH 13 2h 1-68 Rev. 5qi SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />