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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ ------------------------------------------ <br /> (Complete .._ <br /> {Complete in Triplicate} Permit No. _1171(09 <br /> -___-__.__ This Permit Expires 1 Year From Date Issued Date Issued'�5-_g-1)._.. <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 CountyOrdinanceNo. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ---- - --------10 -- - ---------------- <br /> Fes* .A— CENSUS TRACT 5 <br /> Owner's Name -------R _(tJ--- -- --------- - ----------------------------------------------- ----------------------------------- ---Phone -- ------------------------------- <br /> Address ------ city ------------------------------ <br /> �y <br /> Contractor's Name -- I --- ------- ---------l h .�•-- --------License # 1?7.37 Phone -------------------------- <br /> Installation will serve: Resident partment House-[] Commercial ❑Trailer Court '❑ ' <br /> Motel ❑Other - ---------------------------- -------- <br /> Number of living units:_---_I____ Number of bedrooms -_-----Garbage Grinder :___:__,____ Lot Size <br /> Water Supply: Public System and name --------------- _--___Private [ � <br /> Character of soil to a depth of 3 feet: Sand'[,+ Silt F1 Clay ElPeat❑ Sandy Loam lay 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------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ -•---- <br /> Distance to nearest: Well _.._.____-_________________________Foundation ---------------------- Prop. Line -------------- ....... 6 <br /> LEACHING LINE [ ] No, of Lines ----------------- Length of each line --------------------------- Total Length ______-_______-____.______ <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------_---_-_______________-_. -_-.- <br /> Distance to nearest: Well _______-______.__-___-_ Foundation ------------------------ Property Line ------------------------ (il <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes 0 No E] . <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- D <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- ! <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------- ---------------- Date ----------------------------------) C$ <br /> SepticTank (Specify Requirements) ------------- ------- ----------------------------------------------------------------------------------------- •--------------------------- <br /> Disposal Field {Specify Requirements) --=--------------------------------------------------------------------- -------------------------- <br /> ---------- <br /> ---- ---------------------------- -------------------------------- - ,r��_ -------------- <br /> If <br /> --------------------------------------------- <br /> (Draw existingd required <br /> anre q 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 toWorkman's Compensation laws of California." <br /> Signed --- -- --- ------------------- Owner <br /> BY c. itie <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------- --------------- DATE r�'�` '���------------------------ <br /> BUILDINGPERMIT ISSUED ----- ------- ------- ---------------------------------------------------------------------1----- --------DATE -..---------------------------------- <br /> ADDITIONAL COMMENTS <br /> t---------------------------------- -- --------------------------- -------------------------- - ------------------------------------------------- -- --------------------------------- <br /> - -- - <br /> --- ---- <br /> Final Inspection bY: ------- --------------------------------------------- -------------------Date ' -�j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />