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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .... .............•-•-•........I........ Aermit No. ...7�•..... <br /> (Complete in Triplicate) <br />•.•_-,•-•,................... ----------.......•.... This Permit Expires Year From Date Issued Date Issued <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 /> JOB ADDRESS/LOCA ION ..�.�,��.� s'�../.��..r_ _. . r � �-t�:...............CENSUS TRACT ....... ........... <br /> Owner's Name .... 12.F?. .._. �JG�..:.................... ....•-•---....._..-----:..-._:..........'..........Phone :.......................... <br /> .. <br /> Address _.._..--.......... ...-� .. 7 �.._../T Prt?.+",►/.............. .....•. City .. r� ..................................................... <br /> Contractor's Name _..........License # ........................ Phone <br /> Installation will serve: Residence partment House(] Commercial❑Traller Court 0 <br /> - --YMotel 0 Other .......... <br /> Number of living units:.-.-...... Number of bedrooms .�------Garbage Grinder ...... Lot Size .___-IA .......................... �. <br /> 4 ©' <br /> Water Supply: Public System and name .....---•---'----------------------._.........................- -.........----•------------------•...........Private <br /> Character of soil to a depth of 3 feet: Sand_ ,_!.Silt❑ Clay'D Peat 0 Sandy Loam f:] Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If y,s,type ----------------•------- i <br /> (Plot plan, showing ,size}of lot, location of. sysfem-in-relation--to wells,-buildings,-etc, must be placed on reverse side.( <br /> NEW INSTALLATION: . (No septic tank or seepa a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT' [ } SEPTIC TANK� Six ------------- Liquid Liquid Depth .......................... <br /> 1.2.a?l��'------ Type�,�QG--_.:. _.... Material 4o;,.e.P-"•� No. Compartments ............... <br /> D'stance to nearest: Well ...---I..Q_:f................Foundation .---�Q.--:- -:-- Prop. Line . .... '?f^1..... <br /> .., <br /> r <br /> LEACHING LINE ( No. of Lines ........................ Length of each line--- --.....��'_,, ,Total .Length --- ............... <br /> 'D' Box ___.._ Type Filter Materials s7 &4__Depth Filter Material .`�1..............................:... <br /> It - r <br /> Distance to nearest:-Well /PO................ Foundation .............. Property Line .................. <br /> SEEPAGE PIT ( ; Depth ................ ..Diameter ................ Number ............................ Rock Filled- Yes ❑ No <br /> Water Table Depth .........Rock Size <br /> Distance`to nearest: Well ..........................•.............Foundation .................... Prop. Line ....... .............. <br /> REPAIR/ADDITION{Prey. Sanitation Permit# ....................-....................... Date _... ........................ <br /> Septic Tank (Specify Requirements) ...--------••---••...................................._------------•---.._....-.................................. ................... <br /> ....,_ q: <br /> Disposal Field (Specify Requirements) --.................................................._..--.-..........-•........................................• •....----------- ; <br /> ........................ .............-----------------:-=------- - .----•---- ------ -__-_ • ___---...... <br /> (Draw existing <br /> .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 s ch manner <br /> as to becomeroc, o W r s Comp nsation laws of California. <br /> Signed ------•----•------- Owner <br /> By ............................................................._......................................... Title ............>:.....................................................----> <br /> (If other than owner) <br /> I:OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------•-•---- ......-• ...•--.....................................•---_.... DATE ,,C�?.`. ..� .... <br /> BUILDING PERMIT 'ISSUED. ......DATE "'' <br /> ADDITIONAL COMMENTS ..................... `' <br /> --------------------------------'.............................................---•......................... ......... ............................. ..................•-•............ <br /> ------..._.--........--•...................•---......--:. ........ -•-•-------•----- ......................................................._............................... <br /> <-----------------------------------------------------:.---•-----............... ......... .... ....... <br /> Final Inspection by: ° ,... . ��— <br /> ........... •._ Date .............. ......... ...... <br /> SAN,'OAQUIN LOCAL HEALTH DISTRICT <br /> 7172 3 M A- <br />