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FOR OFFICE USE: <br /> ------------------- �APPUCATION FOR SANITATION PERMIT Permit Nci&�_ <br /> (Complete in Triplicate) <br /> ,s - ------------- ------ <br /> �r r <br /> --------------------- -.-_-------.---;--------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the,San herein <br /> ,San Joaquin Local Health District for a per,mit to construct and install the worl he in <br /> described. This application is made in compliance with County Ordinance No- 549 and existing Rules and Regulations: <br /> ----- - <br /> JOB ADDRESS/LOCATI 13 ----- --------------CENSUS-TRACT _31-1;------ <br /> - - --- -----------Phone ---------------------- �'= <br /> Name --------- <br /> Address ----------------------------- - -7-X-------- ------ ------ Cit,---------- ----------------------------------License Contractor's Name ---------------- _wv LPhone�---- -------------------- <br /> Installation will serve: Residence VApartment House[] Commercial :E]Trailer Court 0 <br /> M6tel b,❑ Other ----------------------•-------------------- <br /> ,�__ ------ Lot Size <br /> Number of living units---- ---- Number of bedrooms -------- <br /> arbage Grinder <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------I-------------------Private <br /> Character of soil to a depth of 3 feet: Sand'El Silt 0 Clay El Peat El Sandy Loam El 'Clay-Loam El <br /> Hardpan E] Adobe fto' Fill Materia"10---- If yes,type ---------------------------- <br /> 2f <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 TAW:[ Size------------------- F- Liquid Depth ---------------- <br /> Capacity --- --------------- Type,.-------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest; Well ------------------------------------Foundation ---------------------- Prop. Line ---------------- <br /> I .NJ <br /> .LEACHING LINE No. of Lines ---------------------I_ Length of each line-_-_______-__--_-._____ Total Length -----------------_-_-----_-_- <br /> 'D' <br /> --------- --D' Box 'J---- -- Type Filter Material --------------------Depth Filter Material -------------------------------------- <br /> t <br /> Distance to nearest: Well -------------------------- Foundation <br /> ------------- Property Line - <br /> ---------------I.:------ <br /> Rock Filled Yes E] No'0 <br /> SEEPAGE PIT Depth -------------- Diameter ---------------- Number ----- -------------------- <br /> Water Table Depth -------------------•----------------------- ------ -------_Rock Size ----- ........................ <br /> - -------------:------- Prop. Line ----------- <br /> ------------------- - <br /> Distance to nearest: W&I <br /> 1- --- -��_t__!77:�_7!Founcldtlon-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------ -- Date ............ --_-_----_} <br /> Septic Tank (Specify Requirements) .......... --------- - - -------------- --------e----------- <br /> V ---------- <br /> Disposia�d (Specify Require eats} ---------- - ---------- - ------- ------------- <br /> ti <br /> --------- --- - <br /> ----------- --- - ------ ------ ----- --- -- <br /> ---- -- ---- ---------'-•------ .... <br /> ------------------------------------------------------ <br /> ------------------- <br /> --------------------------------------------------------- J------------------------------------------------- --------- <br /> ------------------------------------------------------------------- <br /> (Dqw existing.and_required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be 11% 'accordance With San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Heaa� 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 Workman's Compensation laws of California." <br /> f <br /> Signed -------------------------- ----------- - --------------- -------------------- Owner-,, <br /> By ------------------------------------ -"-- -- - -- ------- ------ Title --------------------------------- <br /> (If other th <br /> an er) <br /> e <br /> "PARTMENT USE ONLY <br /> APPLICATION ACCEPTED --- ----- -------------------------------------------- DATE ------------------- <br /> BUILDINGPERMIT ISSUED ------------- ----- - ----- ------- ----------- --- ----------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMM -- - - -- ------I--------------------------------------------------------------------------------------------- <br /> M - -—-------- ------------ --- -------- <br /> 71,­ ------ <br /> --------------------------- <br /> ------------------------------- -- ------ ------- ------- -- ----------------- - -- ------------------------------------------------------------------------------------------------- <br /> ---------------- ---------------/--------- - ----- ---- ----------------------------------------------------------------------------------------------- ------ ---- <br /> ------------- <br /> Final linspection by: -------- -71 - - - -----------------------------------------n-�------------------------------------Date <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 3-'66 Rev. 5M <br />