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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ 3 <br /> ----------------------- -- - - - - Permit No. _- ----- <br /> �' <br /> ----------------------- - ------------ (Complete in Triplicate) <br /> Date Issued <br /> -------------_______-------------_--------------- This Permit Expires 1 Year From Date Issued <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 withfourpty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION N'.,E__- -+�C�"lZrve4-----ryustirv---!-_A: I4 Et/0,4-----A*� CENSUS TRACT --------------•-_--------- <br /> Owner's Name 1SA_be-1 ,4-------------i 4oe.,rt----------- - _ ------- ---Pho e <br /> Address /�S'� eI --------.t'zri ,v"ck �EJt ..__" p, Cityf !✓J C C --------------- <br /> Contractor's Name _ ____ /lith 'h----IA/---C��i------------- -------License #/ Phone <br /> Installation will serve: Residence V Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--I-------- Number of bedrooms ---/.......Garbage Grinder ------------ Lot Size -_-__-_-_".__-----__---------------------- <br /> Water Supply: Public System and name -------------------------------•-------------------------------------------•------------ -----------------Privateer <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam,t Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <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 .-------_---------------- N4 <br /> Capacity "------------------- Type ---- --------------- Material--------------------- No. Compartments ------ ISO <br /> Distance to nearest: Well __________._______________________Foundation ____----.__.________. Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ___QWe Length of each line----7e_ ------------- Total fLeQQngth ,_2Q. ............... <br /> 'D' Box ____________ Type Filter Material __c_v ____Depth Filter Material . 4t_n._____ <br /> ------------------------------------ <br /> - Foundation ___. --------- Property Line _�................. <br /> SEEPAGE PIT [ ] Depth __________________ Diameter ---------------- Number---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation ------ ------------- Prop. Line _._-____------ _----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ------------------------ --••------------------------•-•- <br /> Disposal Field (Specify Requirements) ------------ ------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------­--------------------- <br /> ------------------------ <br /> ----------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 /> SigVne ., " .- ----------------------------------------------------- ----------- Owner <br /> BY --- 7nt sr--,- n....... Q 1e_----- ',€, ? f 1- I�d?�Title - 1 - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _______ ______________t___ �� <br /> - DATE <br /> BUILDING PERMIT ISSUED ------ --------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------ ------------------------------------------------------------___-----------------------------------------........................... <br /> ----------------------------------------------------------- ---------------------------------------------------------- -- ----------------------------------------------------------------- ------------- <br /> ------------------------------------------------------- -- -----' - - - - - - - - -Z- <br /> - <br /> ---------=------- <br /> ----------- <br /> Final Inspection b _._-_-__ ' - Date ---.----_" � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />