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Mm UPTILM <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................................................... #Complete in Triplicate) Permit No. .. 77-3-S-7 <br /> This Permit Expires 1 Year From Date Issuer! Date Issued . '.`.... ..:77 <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 applicationIs <br /> �made,Inn compliance with County.Ordinance No. 544 and existing Rules and Regulations <br /> JOB ADDRESS/LOCATION L.��. 1.. . . .............................................CENSUS TRACT .......................... <br /> Owner's Name .. p� ............................................ ,. ...................................Phone <br /> Address ............................................................ ............................-.............City --•----•............................................................... <br /> ..... <br /> Contractor's Name .r.. -- f•.............................................License #Me?.kj;... Phone ..*2C.:.1, <br /> Installation will serve: dance Q3-2!partrnent Houses] 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 Mcterlal ............ if yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must bre placed on reverse side. i <br /> ,NEW INSTALLATION: (No naptic tank or seepage pit permitted if.public sewer is available within 200 feet,' <br /> PACKAGE TREATMENT ( ] SEPTIC TANK{ ) ............. Liquid Depth .................. <br /> K Sixe... ......--•...................... ........ <br /> Capacity� �Q ���ype -----•-•--._. Material...................... No. Compartments ... - ..---... <br /> a►�' ' ,-Distance to nearest: We ...ftp.........................Foundation q ............. Prop. Line _ <br /> LEACHING LINT No of line �- --------------- Length of each line .�. .-.... <br /> I D s ng - .................. Total length ..� .............. <br /> T .....Depth Filter Material . ......................................r � <br />� . ..D' Box --l---•--.. Type Filter Material � �.....� 9, <br /> Distance to nearest: Well- ........:........ foundation ........................ Property line ........................00 <br />". SEEPAGE PIT [ Depth .................... Diameter Number ............................ Rock Filled Yes ❑ No 0 <br /> Water Table Depth,......................... .. .Rock Size . ti <br /> .�Distan to nearest: Well ................... •..............Foundation .................... Prop. Line ......... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ............:......f.......... .::....... .....__._............................................._... ............................. . <br /> � <br /> 7 <br /> DisposalField (Specify Requirements? ---•----......-•-•...................•----................_....-------•------...........................-----•-- ..................... <br /> ...........................................................-............................ .......n.............................-.........................................................I................. <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 vAth San Joaquin <br /> County Ordinances, State Laws, and Rules and-Regulations_of the San Joaquin Local Health District. Hoene owner or Dean- <br /> sod 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 becomA subject to orkman)Compensation laws of California." <br /> Signed . Owner <br /> By ................................. -•.............. .............•-......................-----•-•----.. Title ........-... .......-.............................................. <br /> 'Vf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY — ............ DATE ... ✓ ~'Z��,, .. <br /> BUILDING PERMIT ISSUED <br /> .......................... .................... .............................DATE -................................. <br /> ADDITIONALCOMMENTS ....... --• .................................................................................................................................................. <br /> ................................ .....................------.. .1... .....-............-- .................. ........................--...................I................... <br /> ..incl-.nsp .tion......... ktc3rr.... .......... .............. ............... ..................-......... . ......... ... <br /> . .. .. <br /> Final lnspectian by: .--..-. ........ ..- . . .. ..................................................Date ... ..•—�.:Z,.�.:.�,�...... <br /> EH 13 1-68 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />