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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------- <br /> (Complete in Triplicate) Permit No. _. 3_-- ____-__. <br /> -------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued _ J�d�_?3 <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 w thXounty Ordinance No. 5.49 and existing Rules and Regulations. <br /> It 1;1.3" LV . <br /> JOB ADDRESS/LOCATION . z__ '- -_- _. '-- _� "�"" ¢'`_ -.:: I' " IICENSUSTRACT __:__: -- ----__ <br /> rS <br /> Owner's Name -'------ ----....--- � -- Pho a ------------------ <br /> Lal---------------------------- <br /> Contractor's Name --._ 6J ------ --------- _:License # JJ Phone ............................ <br /> Installation will serve: Residence ❑ artment House,❑ Commerci ?: Trailer Court i <br /> Motel ❑ ther ...L— -:^ <br /> z-s`T a <br /> Number of living units:------------ Number of bedroom -------- <br /> __ Ga ge Grind --------- Lot Sizer___________________________________________ <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 E] Adobe'E] 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 /> E NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> LV <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f Size-_rJ --------------- Liquid Depth ___Y______________,___. p <br /> Capacity b4_ Type . n- ___ Material_ ______________-____ No. Compartments __-_�- A <br /> tj <br /> Distance to nearest: Well -------- -- --.___f---d__F,oundation -------L,0_'_____ Prop. Line _-_- ........ <br /> LEACHING LINE ] No. of Lines ---- _�_- ___--_, Length of each line-_------__!-Q_®._1_____ Total Length <br /> 1 i' R o, <br /> 'D' Box _____j--__ Type Filter Material ------S_,9j_Depth Filter Material ________J_17---------------:------------- <br /> Distance to nearest: Well -------- ------ Foundation -------«?_- ._„,, operty Line ---__------___.,_.___ <br /> T. [� Depth � ' - r tX__-rn__ Number ____._____._�___ ____-_ Rock Filled Yes � No C]tZr <br /> Water Table Depth ------------------------------------ ------------Rock Size ---- <br /> Distance <br /> --Distance to nearest: Well -----------I_a_o____________________Foundation ___`E'__________ Prop. line _.------ <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------•----------_._) <br /> Septic Tank (Specify Requirements) ------------- ----- --------------------------------------------------------------------- ------- <br /> ------------------ -,..----------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 /> "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 - - ---- --------------------------------- Owner <br /> B _ -------°:C?-fes. Title ---- <br /> (If other than owner): <br /> i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ .___ -_,____ y__-_-_.-- ._ '�' ' <br /> -- --- --- ------- ---- - - -- --------' DATE _-..�.--------------•------------•------ <br /> BUILDING PERMIT ISSUED ----------------- ------ DATE <br /> ADDITIONALCOMMENTS ------------I----------- ---------------------------------------------------------------------------------------------------------=-------....---------------- <br /> ..--- --------------------------------- I----------------- --------------- -- ---- ----- -------------------------------------------------------------------------- <br /> ---------------------- <br /> ------------------------------------------------------------------------ -----------------------------------------------------------------------==-------------------------------------------------------- <br /> -------------------- ---` -------------- ------------------------------------------ <br /> Final inspection b �= _ ---------- ----------------------- ------- ---------- ----Date ---c� � _ - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M A <br />