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FOR OFFICE USE: d <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- ------------------------------- ---------- -------- Permit No. 71- 3 <br /> (Complete in Triplicate} ---- <br /> --------- --- ----------------- ------------ <br /> ------------------------------__-__._____.__-__________ This Permit Expires 1 Year From Date Issued <br /> 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 /> r described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -------- ----'-----_----- <br /> C?--------K7C3_ - ' c( c --CENSUS TRACT --_---� - ---------- <br /> Owner's Name ------------------------ ��' C ------------------------------------- ----------------------------------------- Phone <br /> Address ------------ �n. 7! X �_?1��------ ---------------- City - pi,----------------------- -------------------------------- <br /> Contractor's Name -- --- ----- ----------' t --------------------------------------------License # 0 Phone ------------------------------ <br /> fnstaliation will serve: Residence [ partment House❑ Commercial ❑Trailer Court ❑ <br /> c <br /> Motel ❑Other ---------------------------------------- 9 p <br /> Number of living units:___.____--_ Number of bedrooms __-9_____-Garbage Grinder _?COS__ Lot Size _.__._[___I T____________________________ <br /> Water Supply: Public System and name ------------------------------------------------------------------ --------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt-0 Clay ❑ Peat❑ Sandy Loam '❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe El"'IFili 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:[Ar— Size___-__1, __________________ Liquid Depth `Z.____________ �1 <br /> Capacity _I&W--_----.__ Type J`h?2 No. Compartments �`" <br /> t \ Distance to nearest: Well -----(-M-'f----------------------Foundation ----W------------- Prop. Line <br /> LEACHING LINE No. of Lines �!! F <br /> [ ] 1---------- - --- Length of each line--------- ------__-_-- Total Length -- �-�------_------- <br /> it <br /> 'D' Box .-W—)---- Type Filter Material _:__ __A�_____Depth Filter Material ------- ----------------------- <br /> Distance to nearest: Well . -------------- Foundation <br /> __-�n____________- .Property Line <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No C <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> _. I <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date --------•------------------------_) <br /> rSeptic Tank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- .--------------------------- <br /> DisposalField (Specify Requirements) ------------------- ----------------------------------------------------------------------------------------------------------------- <br /> ----- ------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> J <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 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 such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - ----- .-e-------- ----------------------------------------------- Owner <br /> BY ------- ----------- Title ---------- -------- <br /> --- ----- <br /> - -------------- <br /> --------------- ------------------------------------- - - - =----------------------------- <br /> (!f other than owne <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------- --------- - ---- ' DATE -6r_ <br /> BUILDING PERMIT ISSUED ----- -------------------------------- --------- ------------ ---- --DATE ---------------------7--------------------- <br /> - --------- <br /> ADDITIONALCOMMENTS = -- ------ --------------------------:--- --------- ---------------------------- ------------------------------------- <br /> - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- ------------------------------------------------ ------------------------------------------------------------------------- ---- •---------------------------------- -- <br /> ----------------------------------------------------------------------------- ----------------------------------- - ' ----------------=------- <br /> Final Ins ection b ; <br /> p Y = ------------------------ <br /> --------_ Date ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT) <br /> E. H. 9 1-'b8 Rev. 5M C ' <br />