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FOR OFFICE USE: <br /> I �- "' APPLICATION FOR SANITATION PFRMIT <br /> ��..................................................... '� <br /> •1. (Complete in Triplicate} Permit No. ...................... <br /> ......... ............................ This Permit Expires 1 Year From Date Issued Date Issued ....._ <br /> _ <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .(/� _ ..............CEN5U5 TRACT <br /> :.....7..._ :# t C �f <br /> Owner's Name ..........L`�.1�:�.. .... .... . .........Phone <br /> . <br /> .... •_- <br /> Address ---- ---------------------- !._..._.. .... City .......... <br /> Contractor's Name ----- ------- -------- a z-[/�-------------'-'License # :>7: Phone . .:: �i. .7.... <br /> Installation will serve: ResidenceApartment House C] Commercial ❑Trailer Court- 0 <br /> Motel ❑Other ..................................:......... <br /> Number of living units:......f Number of bedrooms --..yGorbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ............... . .Private ❑ <br /> Character of soil to a depth of 3 feet: Sand]] SfIt[Q Clay ❑ Peat❑ Sandy Loam fl Clay Loom 0 <br /> Hardpan ❑ Adobe❑''fill Material ............ If yes, type ............................ <br /> 7 (Plot pian, showing size of. lot, location of:system in relation to wells, buildings, etc. must be placed`°on•.,reverse side.) <br /> R. <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,} <br /> I PACKAGE TREATMENT [ ] SEPTIC TANK$ ] Size................................................ Liquid Depth .......................... <br /> Capacity -------------------- Type ... :... AAaterial.---- ----------.... No. Compartments ............... <br /> Distance to nearest: Well: .............................S ...Foundation ...-.................. Prop. Line ....... .............. <br /> LEACHING LINE [ ] No. of Lines ..........:......... Length of eoch�lline-........................... Total Length ...._... ..................... <br /> D' Box type'Filter Moteriah`...:.-..__.._ p <br /> ' Depth Filter Material <br /> Distance to nearest: Well :'................. .... Foundation ........................ .Property Line ....................... <br /> ` SEEPAGE PIT E ) Depth ••..:. Diom6ter ..:'. ....... Number ... -.--------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth <br /> ` -•--•----- ...........................Rock Size ................................. <br /> Distance to nearest:.Wbli - -----------------------------------------------Foundation .................... .Prop. Line ........__...._._-.... / <br /> REPAIR/ADDITION IPrev. Sanitation Permit#•--------- ..................... Date .................................. <br /> Septic Tank (Specify Requirements) ... ............ ... .................... .). ........------------ ......... <br /> m ._......... <br /> Disposal Field (Specify Requirements) ... ..?.�� r�}t Y�------- - ,`----r.. ..-..------•---•----------------- <br /> ...........•---------........ --------------------------------------- --- --------•---------••----------------------------...--•----------•-------•-•------.._._._......----...__......---•----•-- <br /> .(Draw existing pnd 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 Son Joaquin Local Health District. Home owner or Iicen- <br /> sed agents signature certifies the following: ! I <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 /> SignedOwner <br /> By ......... • - Title ...... <br /> (I of r hon owner)' E� <br /> FOR' DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -�2 <br /> BUILDING PERMIT ISSUED ..............DATE <br /> .ADDITIONAL COMMENTS _._._._-• ....... ................................................................................................................................... <br /> ---•---•...........................__..______.....___._._.... .............-------•-...-•••-----•----•---•-••••-•••----....---•--• ---••------------------------------- <br /> ........ <br /> .............................................. .. .---'--._......_..........._._.._i'-•--•-•------•....---------------•--..............a..........._._........_._..... ------- <br /> ----------------------------------- <br /> .. ... ..............................................................................I.......I._......_.__. ._.................. <br /> k Final Inspection by: '" .. .................. <br /> � _.. ..... ...... .......................:.. ....................................................•--•--•------•.Date .....:. <br /> — SAN.JOAQUIN LOCAL HEALTH DISTRICT <br /> k E. H.13 241-'G8 Rev. 5M7/x72 3 M <br />