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FCtR OFi'ICE USE.'*� <br /> 3` 30 APPLICATION FOR SANITATION PERMIT <br /> .................... <br /> . 5 <br /> lGonrplete in Triplicate) � Permit No <br /> ................................................ <br /> This Permit Expires 1 Year four Dot*lsiued nate Issued .`--------.rki. <br /> 1 <br /> Application is hereby made to the San(kaquin Local Health District for a permit to construct and install the work herein <br /> described: This application is made in compliance wit ' untr Ordinance No. 549 and existing Rules and Regulations: <br /> JOB A©DRESS/LOCATi �.-.�... -. <br /> .... ... ...-- ---•- - ........�-n.............. ............CENSUS TRACT � <br /> Owner's Name ..... ............... . •-- •---•- ... .........................................:...........Phone .................................... <br /> Address ... �C�- .... ----------------------- <br /> ,-.-.- ....... <br /> .. City ....................... .............................................. <br /> -------------- - ------- ----- <br /> - 4 y <br /> Contractor's Name .... --••...... License 4['` .,�.�-, 1.. Phone f ��� �` <br /> I <br /> Installation will serve: Residence fl Apartm t House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other-•-•-• .............. ....................... <br /> Number of living units:-I...... Number of bedrooms ..... Garbage Grinder ...........- Lot Size -; -=•�- ... .'... .... ...... I <br /> Water Supply:.Public System and name ........6----- ..Private ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ ' Clay ❑ Peat[3 Sandy Loam 0 Clay loam] <br /> . r <br /> Hardpan❑ Adobe❑ Fill Material ............ if yes,type <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side:) ,4 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK I ] 6d�i '(....4-0....... Liquid Depth k,............. <br /> Capacity - ,- - - Type �, -------- Material.- -_-.. No. Compartments .._0_�- ..------ <br /> Distance.to nearest: Well -•---...---•........................Foundation ...................... Prop. Line 6........ <br /> LEACHING LINE [ ] No. of Lines ._ `------------- Length of each line.....-- Total Len th .......----------- <br /> :.__...._. <br /> 4 g <br /> 'D' Box .. ------ Type Filter Material -----f.�, �Depth .Filter Material ............................................ <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ..............I......... <br /> SEEPAGE PIT {.,]� Depth - (.I Diameter -------------._. Number ..... .................... Rock Filled Yes ❑ No C] ? <br /> Water Table Depth ------------- _..Rock Size <br /> Distance to nearest: Well ----------------------------------------Foundation ---................. Prop. Line ...................... <br /> REPAIR/ADDITION Wrev. Sanitation Permit# ...........................___--__-_-...... Date .................................. <br /> ) <br /> SepticTank (Specify Requirements). .................................•.........-................................--------....... ................._...----•..................... <br /> DisposalField iSpecify Requirements) ---------- -•-------- ................----......................•..........6......................................................... <br /> •-•--------------------------------------------------- - --- -••------ ----------------------------------.................................... <br /> ----------------------------------------------------------- -- ----------------------------------------........................ .................... ................................................. <br /> (Draw existing and required addition on reverse side) j <br /> I hereby certify that I have prepared this application and that the work milli be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Nonce owner or liven. <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 /> Signed --.. --- ..... Owner <br /> BY ....... -- ••- Title ----- .. I <br /> -...- <br /> If oche than owner) 1 <br /> i <br /> FOR DEPARTMENY USE ONLY <br /> APPLICATION ACCEPTED BY -:.. k`�.-- DATE ... ..l. .45_6...............: <br /> BUILDING PERMIT ISSUED ------- --DATE .......... .. <br /> --------------- <br /> ADDITIONAL COMMENTS - ' <br /> --- ----------- - ------------------------------------- -----...-- —...- .... ---------.-.......--........-- �..-...-----.......--- .--............. <br /> ---•---•---------------------------•.-...-•-------------.------------------------------ <br /> FinalInspection by: --------------.. ----------- ........... ----............-.- ........................ � � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h: 3M <br /> i <br />