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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ........................ G3 <br /> )Complete in Triplicate) <br /> Permit No. ..................... <br /> ...... This Permit Expires 1 Year From Date Issued Date Issued ... :.0�3...7� <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 existing. Rules and Regulations: <br /> JOB ADDRESS/LOCATI !'���! .- -. -�h._- <br /> _ r�...�J'. ............................._CENSUS TRACT ........................... <br /> Owner's Name ........... . . ......._D-- ..•... . •----------•• .:...... Phone .................................... <br /> ., <br /> Address ....................... 5�. .._..._ kow...e &City .... . r¢ ,'........ <br /> -- -- - <br /> License # �......__... _ Phone .............................. <br /> Contractor's Name ._._.._ .. ....- -- . _... e �� � <br /> Installation will serve: Residence ❑ Apartment Ho e❑ Commercial Trailer Court `] <br /> Motel ❑Other _---- <br /> Number of living units:.._-f'�._-_ 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 Z] Silt❑ Clay (3 'Peat E] 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[ 1 Size----------------------------------- ------------ Liquid Depth ....................... <br /> Capacity Type ------------- Material...................... Na. Compartments <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...............I...... lor <br /> LEACHING LINE. [ 1 No. of lines <br /> ------------------------ Length of each line---------------------------- Total Length _........................... �t <br /> V Box ------------ Type Filter Material ....................Depth Filter Material __..-____..._..___....... ............. <br /> Distance to nearest: Well ......................... Foundation ---------I.........----- Property Line ...................... <br /> SEEPAGE PIT O Depth -------------------- Diameter ................ Number --------------------------.. Rock Filled Yes ❑ No C] <br /> Water Table Depth .................Rock Size <br /> Distance to nearest: Well ................... . _____._.Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDIT€ON(Prev. Sanitation Permit# _........................................... Date .........................._-_--__-) <br /> Septic Tank (Specify Requirements) ---- <br /> ----------•------•-----• ......... <br /> ..._.. <br /> � . ---------- <br /> Disposal Field lS ecifY Re uir mentsI _... . . <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 clone 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 /> By .... ............................... ... .: Title . <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........�e............. ....... - . . .........._..._....... DATE _... ..�s...7. .._.._...... <br /> 01 <br /> ..... <br /> BUILDING PERMIT ISSUED /A ? ..................................................•-•. --- ..........DATE ................... ------------...._...._ <br /> ADDITIONAL COMMENTS . I .......� z G. . ...--•--•.............. <br /> - ----- ---- --- ------- ----- ----------- <br /> Final Inspection by: .........Z-' = ....Date ..... .1 17 <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev.-.5M 7/72 3 M <br />