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FOR OFFICE USE: <br /> APMCAU0AN FOR SANITATION PERMIT <br /> ------------------------ ------------------------------ Permit No. =j <br /> (Complete sn <br /> Triplicate) <br /> -------------------------------------------------------- <br /> Date Issued <br /> ------------------------- -------------------------- ThisPermit Expires 1 Year From Date Issued <br /> r <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> �j __ / - > lENSUS TRACT ------------ ------------- <br /> JOB ADDRESS/LOCATION -------- -------- /,l <br /> Owner's Name ---- 44,1112_4^40 ---------------------------------- ------i --------- -------------------Phone---------- ------------------------- <br /> Address �sr--�-------------------------------------_. City - ------ --------------------------------------------------------- <br /> Contractor's Name - /.�_ ---------------------------- --•-------•- --------------- -----=-------.License # ------_----------------- Phone ---------------------_------ <br /> Installation will serve: Residence IF Apartment House-[] Commercial ❑Trailer Court ,❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number.of living units:-----I----- Number of bedrooms -_A----..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 .E] Peat ❑ Sandy Loam ❑ Clay Loam :® <br /> Hardpan PP Adobe ❑ Fill Material ------------ 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;( ] Size---------------------------------- ------------ Liquid Depth ---- _----.---.----- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ----------. --•------ ' <br /> Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--------------- ------------ Total Length ----------------..---------- <br /> 'D' Box --•--------- Type Filter Material --------------------Depth f=ilter Material ----------------------------.--------------- <br /> Distance to nearest: Well ------------------- -- Foundation ----.---------_-------- Property Line -------------------:.--- <br /> SEEPAGE PIT [ ] Depth ---- --------------- Diameter ---------------- Number ------.-----_-------------- Rock Filled Yes ❑ No ❑ <br /> c <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well .---_----------------------------------Foundation -------------------- Prop. Line --------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------.--------------1 <br /> 3 <br /> Septic Tank ]Specify Requirements) ------------ --------------- - ------------ --.1-------- - ----- ---------- ' -� ------------------------------------•-- ------------- <br /> Disposal Field (Specify Require ents) <br /> -- ---------------------------------- <br /> ------------------------------------------------------------- <br /> ----------------------------------------------------- ---------------- ------------------------------------------------------------------------------- --------------------------- ----------- ! <br /> (Draw existing and required addition on reverse side) <br /> 1 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. Son 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 bfcome subject to Workman's Compensation laws of California." <br /> Signed/)M?--� --- -- ---- <br /> ----------------------------------- Owner <br /> - �!- <br /> Bye--------------------------------------- -------------------------------------------- --------------- Title --------------_------------ ------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE .ONLY <br /> APPLICATION ACCE - - 7 � h <br /> � <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------- I---------------------------------------DATE ------------- -------- <br /> ------------- ------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------- ' -------------------------------------:------•------------------- --------------------------- <br /> ►� --------- ---------------------------------------- --------------- <br /> ----------------- ---------------------------------------------------------------------------------- <br /> ' ---------------------------------------- <br /> ------------------------- ----- ----------- ----------r:------- ------ <br /> ---- ------------ --------- <br /> -------------------- ------- -------- --- - <br /> Date - <br /> Final Inspection by: 4 --------- fi ------- <br /> -------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />