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FOR OFFICE USE: <br /> �y APPLICATION FOR SANITATION PERMIT <br /> ------------- <br /> Permit No. -71-----8-Z- <br /> ------=-- .3 <br /> (Complete in Triplicate) Date Issued _- <br /> --- ------------ - --- -- <br /> D _ This Permit Expires 1 Year From Date Issued------------ <br /> ; <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: i <br /> JOB ADDRESS/LOCATION Aul� -:.------sG.z !['� ----- ---------CENSUS TRACT -------------------------- <br /> Owner's Name ---- -�v�'-�------------ ------•----- ---------_;--- - ----- -•-------------------Phone AOZ.77 • <br /> Address ------- <br /> ------------------------------=------ -- <br /> �• - -- <br /> -----------------------------------•- City _-- <br /> Phone <br /> Contractor's Name /Ate --� -7----��-�/��-------- ----- License # 12 � - <br /> Installation will serve: Residence [g Apartment Housef] Commercial:❑Trailer Court <br /> Motel ❑ Other ---------------------------------------- <br /> Number of living units:_--/------- Number of bedrooms _--------Garbage Grinder /Y- -C) 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[3 Sandy Loam -El Clay Loam '❑ <br /> Hardpan ❑ AdobeX 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 /> Ca acit Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well __.---------------------------------Foundation ---------------------- Prop. Line .............:........ <br /> F <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each Eine---------------------- Total Len--- gth ----------- ----------- <br /> 'D' Box ------------ Type Filter Material ---------------------Depth Filter Material ----------------------- ............... <br /> Distance to nearest: Well ------------------------ Foundation .--------------------- -- Property Line .-.__.__.-------...-.--- <br /> k _ Rock Filled Yes ❑ No <br /> I SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------------------------- <br /> Water Table Depth ------------------------------------------------Rock <br /> 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) ------ ,I/,STS'A4------- ,p----------r -�`- C-3 ����cr ------------------ <br /> �19&1j1AC�---/-V- -- -XIA1,-------------------------- ----------------------------------------------- <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 /> "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 subjec o Workm n's Compensation laws of California." <br /> Signed -------------- -------- -- --- Owner ` <br /> -i <br /> BY ------ ------- ----------- - --- ------------ <br /> Title ------- --------------------------------------------------------------- <br /> [If er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> -'- � - -- <br /> APPLICATION ACCEPTED BY ---------- ' - DATE -= ---------------------f- <br /> BUILDING PERMIT ISSUED ------------------- _DATE --------------------------------------• <br /> ----------------- <br /> ADDITIONAL COMMENTS ---------------------------------- ----------------- ---------=-------- ------------------ <br /> ------------------------------------------------------------------- -- -------------------------------------------------------------------------------------------- <br /> -------------------------------------------------- - <br /> ------------- ---- ------- <br /> ------------------- ------------------------------------------- <br /> --------------=-------------------------------- -- --------------- -- ----- ---- <br /> ------- -------------- <br /> ----=------- <br /> Final Inspection by: ------------ --- -------------- ----------------------------- <br /> Date ------ - -- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 . 1-'6$ Rev. 5M � w s <br />