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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . 6 7 <br /> (Complete in Triplicate) Permit No. .7.3,`9 <br />..-...... _.......... - • -���--------------- /a -/7-7..3 <br /> ....................... This Permit Expires 1 Year From Date Issued 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 /> described. This application is made in compliance with County Ordinance No. 549 and existin Rules and Regulations: <br /> JOB ADDRESS/L CATION ..............0 CJ!. ��- .__...'......-_...._ ....... ..CENSTRACT ......................... <br /> Owner's Name - 0Z.__• -• • . p ... ......... ........................................._....•••........_..._....._.....PIn e .._ — Sy <br /> Address _ { ------ •---•------••-••--•• ... City ............................................................... <br /> Contractor's Name .. F/ :. . n. _._..License <br /> ❑ P ❑ ❑ I] ......... <br /> Installation will serve: Residence Apartment House �,•Comterc Trailer Court �urwcK <br /> Motel Q Other . _'\`l ? -r.............. <br /> Number of living units:_......... Number of bedrooms ............Garbage Grinder ............ Lot Size -. <br /> Wdteir Supply: Public System and name .................................................................................-..............................Private <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe K 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 /> PAC GE TREATMENT [ ] SEPTIC TANK t Size................................................ Liquid Depth ........................... <br /> Capacity .' TYPe _..._ Material.C ._. No. Comportments ..4 ..............t74 <br /> j ® , J <br /> Distance to nearest: Well ..... __t...................Foundation ..lfl.__ ......... Prop. Line ........ ............ <br /> LEACHING LINE 'j j No. of lines ...-I.................. length of each line...... _V*-_............... Total length ...ao................. U <br /> 'D' Box ............ Type Filter Material .....Depth Filter Material ..... . ..... ........................... N <br /> Distance to nearest: Well ._�. . ........... Foundation ....�f?��_._.....__. Property Line ._ � .............. <br /> SEEPAGE PIT [ ) Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No iD <br /> Water Table Depth .............Rock Size <br /> Distance to nearest: Well ________________________________________Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> SepticTank (Specify Requirements) -----------•--------------------------------•--------•----•--------•--••---...----....--•--------------•----........--•.....--•-••--.................. <br /> DisposalField (Specify Requirements) ------••------•--•----------------------•---•---•-••---...___...------••-------.....___.__.....----._.•••--•--•--•......-•-•----_.._. <br /> ....................................................................•------•••_._........-_••_____.� <br /> ..........I............ ...................................... ........................................._.................................................................. ......................... . <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 . --------r f --- .... • •--- -• ••--•-•. ................................ Owner <br /> BYx + .......................•••-•-••_...._.. Title ......... •---.._.......---•-------- <br /> (If of r tha own <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... .... ............./ ...��� c.._.._._..•--....•••••.._......_...... ... DATE _._.A©_'. ...�_.•---••---- <br /> BUILDING PERMIT ISSUED -------� DATE ........................................... <br /> -----•..................... .••......................ADDITIONAL COMMENTS ...-------•-----•................................................._._._.._...__--••----..........--•----- -------------•...._.__.......••-••-... ............. <br /> ............................................................................................... ............................-............................................................................. <br /> ...._........................••........._._........__.._........._..._......... ....... ...._...._.........--••....._..••••••-•-••-••..._...........----........._.....••-......_..._..._._....._....._.. <br /> ------------------------------•-------------.......... ... ...- <br /> Final Inspection by: ...................... xu .___ .. . _ . . .. <br /> .. <br /> SAN JO QUIN LOCAL HEALTH 616RICT <br /> E. H.13 241.'68 Rev. 5M 7/723 <br />