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R OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -- -- ------------------------------------------ 7_ _Z------ 7---- <br /> {Complete in Triplicate) Permit No. _ _ <br /> ---------=----------------------------------------------- <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 ma-,4- ccomplliiance ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATION ._,��___ C_ __ j E f r wf CEI US TRACT <br /> rr r <br /> ADDRESS/LOCATION - �`. 1 -----------1 SUS -------------- -- ------ <br /> Owner's Name --- Phone- ----_. <br /> --------------------------------- ---------------------------------- ------------------------ <br /> Address --------------- 0 ------------------------------------------ City ---- --------------------- ----------------------------------- <br /> Contractor's Name _12i*u----- rt�----- s .______.License # -- ------ Phone <br /> Installation will serve: Rgsidence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> N <br /> Motel E]Other ------------------------------•------------- <br /> Number of living units:----1------- Number of bedrooms ------ Garbage -----------. ---_----------------------------•------------:-------..Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ,❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe] 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------- _ __C__X___ r <br /> 7 '�] �'rK �------------ -- _ Liquid Depth <br /> Capacity .__. _,__ Type Material_ No. Compartments Z <br /> Distance to nearest: Well --------_.`__ _________________Foundation --------I-U--___-__ Prop. Line __4__/----------- 1 <br /> LEACHING-LINE No. of Lines _ Len th of each fine_ . S t Total <br /> C - g - Length l °•! <br /> - jc <br /> D' Box lQ_a"✓rj_._ Type Filter Material _L�-------Depth Filter Material _1__�_______________ __ _ _ <br /> J1 <br /> Distance to nearest: Well -----""_____________ Foundation __)_0_(__.____-__ Property Line --- -�f <br /> r ------------------ <br /> SEEPAGE PIT Depth a: Diameter _�_�----___ Number ----r)_—___.___________ Rock Filled YesZ No [jWater Table Depth -----6-6__1---------------------------------Rock Size __0�X- -pr------------ <br /> Distance to nearest: Well ------ "---- __ Foundation ------ Prop. Line _.___ _..__..__._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit Y# -------------------------------------------- Date __________________________....._.-) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ <br /> r <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed . ------s------------------ ---- ---------- ---------- -------`----'--�-------------------------- Owner <br /> By ------------ --------------------------- ------- l.�L.J- ---------- Title ------h.1d�-_ /t c�-d/cL <br /> (If other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED- -BY --- -- - -------------------------------------------------------------------- ----------------- DATE -----1- t��9)--------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------- --------------DATE -------------------------- ------ <br /> ADDITIONAL COMMENTS - <br /> -----=------------------------------------------------------------------------ ---------------------------------------------- --------------------------------------------------- ----------------------- ,. <br /> -------------------------------- j--------------------------------- --------------------------------------------- -------------------------------------------------------•- <br /> -------------------------- ---------------------------------------------- --------------- <br /> Final Inspection b ------------Date _ `._ _ <br /> SAN JOAQUIIv LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />