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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. ._-�._ <br /> ----------------------------- <br /> ------------- ---------------------- <br /> ---- - <br /> ___ _ __________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the Sa 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 <br /> egulations:JOB ADDRESS/LOCATION _.: .. ___, —_.__n/_l -OQ ]t11�A_ _D_-------------------_______-----CENSUS TRACT __. -� f_..-__. <br /> Owner's Name ---------��-'-Q-hFE-�-� 4!V_rI---------- P_L-- --------------------------------------------------------p� Phone ------------------------- <br /> Address -------------- ------WpQ�-� ____ 0--------------- City -------MI-ricloq------- -- ------------- -------•------ <br />,5 Contractor's Name R CJ4 -J ----'-----------------------------------License # ------ _. Phone -.- <br /> Installation will serve: Residence F_1­75�artment House-[] Commercial ❑Trailer Court ,❑ <br /> 41 <br /> Motel ❑Other ; ------------------=------------ r .f <br /> Number of living units:_-__�_-___ Number of bedrooms ______Garbage Grinder. _ Loi Size ___.C- -�DCa_._ __..________ <br /> Water Supply: PubQ'if ystem and name ---------------------------------------------------------------------------•----------------------------------Private. <br /> r Character of soil to a 'depth of 3 feet: Sand'❑ Silt❑ Clay ❑ -Peat❑ Sandy Loam '❑ 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 INSTALLATIONi (No septic tank or seepa pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK' Size-- -------------------------- Liquid Depth ___ __ - <br /> Capacity 12,0_0------- Type+T2Z.1EFA_8 MaterialCOMCR`T_ No. Cor:npartments ___- __ __._�.._ <br /> i r v <br />... rstance to nearest: Well _____ fi_ ----------Founpdation /a_t_ ---- Prop. <br /> Line ----- <br /> LEACHING __-- <br /> ----------- <br /> LINE No. of Lines __._ ______________ Length of each-.line------ Total Length __r1Q <br /> D' Box Type Filter Material __ROCK__Depth Filter Material _-- __ _ ---- <br /> _ rr <br /> - ----------------- <br /> Distance to nearest: Well ___ .__' :.__ Foundation ___J _ Property Line <br /> SEEPAGE PIT [ ] Depth Diameter ________________ Nuinber ---------------------------- Rock Filled Yes ❑ No i❑ <br /> w. Water-Table Depth---------- -------___-----------------------:-----.--:Rock--Size -- = =--------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____-__-__----•---__-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------;-------- -- ---- Date----------------------------------_} <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------- ---------------------- <br /> Disposal Field (Specify Requirements) -------- ------------------------ <br /> ----------------------------------------------------------------------------------------- ------ <br /> r-------------------------------------,- <br /> �_.W,-.- - -�j - - <br /> r. _ <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 si ature certifies the following: <br /> "I certify tha n the pert a of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to beco a subject to orkm . Compensation laws of California." <br /> Sig ed - --- - --------- _ --------------------------------- Owner <br /> By ---------- ---------------- -- ----------------------- -------- �=Q ' ------ <br /> 'Title ------ -- ------------------------- ------------- ----------- <br /> Ti <br /> (If other than owner) <br /> - _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- �f - ;= -------------------- DATE ------ .`- "' --- <br /> BUILDING.PERMIT ,ISSUED -------------- --------------- - -----------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS ----- -- ----------------- <br /> - - --- - - <br /> ------ ----------------- --- ------------------------------------------,------------------ -------- <br /> ---- --- <br /> - ---- ------------------------------------------------- ------ <br /> ------- - ------- -- - - - <br /> Final lnspe ----------------------------------Date .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />