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FOR`OFFICE'USE: y- <br /> APPLICATION FOR SANITATION PERMIT <br /> V---------------------------- (Complete in Triplicate) Permit No. _ .-. <br /> --------------------------------------------I This Permit Expires 1 Year From bate Issued <br /> Date Issued,07/0- 21el <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/LOCATION ---" 241 <br /> -- `3f'_ 2!d°� � fzs �---r-----------------"-----CENSUS TRACT --------------..---------- <br /> Owner's I�fame � <br /> _� f��t_/Yl/7 Phone <br /> / / ---- q <br /> Addfg5sr/ 7/2 "-5- � 57 <br /> �T City <br /> ......................................... <br /> _ <br /> Contra =s-{�fam.e� 1 // e---------------------------------------License #�9-5 --- Phone <br /> Installation will serve: Residence PApartment House❑ Commerciaf ❑Trailer Court 0 /// <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--i------- Number of bedrooms -__ 3�'_--Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> WaterSupply: Public System and name --------------------------------------------------------------------------------------------------------------Private $f <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat ❑ Sandy Loam .0 Clay Loam ❑ \ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <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 f ] Size-- ------------------ -------------------------- Liquid Depth ----------------_---..---. .; <br /> Capacity -------------------- Type ---------------- --- Materi ---------------------- No. Compartments --- ..........--•--- <br /> Distance to nearest: Well ------------- -------------- <br /> _ <br /> - _-.Foundation ---------------------- Prop. Line __.._-_._-...:......._ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Len th of a line---------------------------- Total Length --------------__....... <br /> 'D' Box ------------ Type Filter M erial ---- ---------------Depth Filter Material ------------------------------•------------- <br /> Distance to nearest: Well -- --------------- ----- Foundation ------------------------ Property Line ----_--_-_--.___-_.__._. <br /> SEEPAGE PIT [ ] Depth -------------------- Dia eter --------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth --- ---------------------------Rock Size -------------------------------- <br /> Distance to nearest: --------- - ----------------------------Foundation ------ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- -- hate ---_-----------------_---_-_-_----) <br /> Septic Tank (Specify Requirements) ----- - ----------- <br /> Di posal Field (Specify equirements) -- ----- --________ -_ ---- -- <br /> ------------------------------- <br /> 1 , <br /> ti <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 /> "1 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 Work an's Compensation aws of California." <br /> Signed ------ Owner <br /> ----------------------- <br /> BY ------ Title--------------- <br /> ------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 11 <br /> APPLICATION ACCEPTED BY --- -- - ---------------------------------------------------------------------------- DATE -------I0'P7 ------------------ <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------------------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS <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 <br />