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FOR OFFICE USE: <br /> 5 !A`€�l�CltAT10N FOR SANITATION PERMIT <br /> ------- Permit No. <br /> (Complete in Triplicate) <br /> --------------------------------- ----------------------- <br /> ._--.."..-"""-____._-__-___--."-"""-""-"-.---__-_-"- This Permit Expires ] Year From Date Issued <br /> Date Issued C� <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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ L ,-__. `----"rT�-�%•-------------------------------------------------------.CENSUS TRACT -------------------....... <br /> Owner's Name Ab"eZI-el ---- --------------------------------------------------------------.--Phone 'W, --------- <br /> Address .__fAv" --------------- City ---------------------------------------------------------------------------- <br /> Contractor's Name �/'s`F`S �F/aI'f�" `5 `�c----------------------------- -=--------License # /-772PYJ----- Phone 26-7---- <br /> Installation will serve: Residence [�-Apartment House❑.Commercial :❑Trailer Court <br /> Motel ❑ Other --------------------------- ---------------- <br /> Number of living units:-_i<---- -- Number of bedrooms __,-,Z___.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 0 Fill Material ------------ If yes,type -------------__-_-_____- <br /> (PI'ot 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,) �I <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity -=------------------ Type -------------------- Material---------------------- No. Compartments ----------------- y <br /> Distance to nearest: Well ------------------------------------Foundation ------ ------------- Prop. Line ---------- .:.,---.-- <br /> S LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length _--_--- "............... (r <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.--_---__-_-_-_-----_.-- <br /> ' Distance to nearest: Well ------------------------ Foundation ---------------- Property Line. --"-"---" "-""".__ -- <br /> " t' <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -----------"---- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --------- ----------------------- -------'-----Rock Size ----------------- ---------•---- <br /> + Distance to nearest: Well -__-____-__-___----"__-__--.-_---,."--Foundation ---------------.---- Prop. Line ----_---------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -- -----------------�-------------------------------- -------------------------------3----------------------- <br /> i _. <br /> Disposal Field (Specify Requirements) ----- ------o._042- 'Y----------�----- ---- - -` Y------------ <br /> ----------------------------------------------- <br /> ----------------------------------------------- ---------- ---------------------------------------------------------------------------------------------------------------------------------------------- <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 /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become ubject to Work an's Compensation laws of California." <br /> Signed ------------- ---- --------------------------------------- Owner <br /> BY ------------------------------------------------------------------ Title --- ---- ----- --------- <br /> (If other than owner) { <br /> FOR Dl: ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --,,,,4-------- --------- - --- --------------------- DATE f <br /> BUILDING PERMIT ISSUED - ----- DATE ------- --------- ---------- <br /> ---------- <br /> ADDITIONAL COMMENTS .— <br /> ------ ------------------��'�' -- ------ ----------------------------------------- ------------- <br /> ---------------------------------------------------- --------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------ <br /> -------------------------------------------- ----------------d----------------------------------------------------------------------------------------------------------------------------------------- <br /> - I--- ------------ <br /> Final Inspection by: ------ ----------------------------------------------------------------------Date ---- d----------- ---- <br /> SAN JOA QUIN LOCAL HEALTH DISTRICT '� ► <br /> E. H. 9 1-'6$ Rev. 5M <br />