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FOR OFFICE USE: FOR OFFICE USE: �• <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- ------------------------------------ 7 <br /> -_--_- {Complete in Triplicate} .. -�-1-1--------------------------- �/� <br /> Permit <br /> ----------- ---A-, <br /> Date Issued___s.___�._77 <br /> _._____.- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install' the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> i <br /> ADDRESS/LOCATION._,Q�. <br /> " ��"� ,,..,( r_:•_4 '���i:----- -- ---- ---� . ------`.__.CENSUS TRACT --- --------------------- <br /> JOB <br /> OwneT.'s Name- ;�fj[J�1 r,S/ l�! --------------------------------------- <br /> � -`� -- ------ - ----- --------Phone --------- <br /> Address_ a +'i� - - i� A�lr._ _ - ----------- ----- - City '�1 Z1P <br /> Contractors 6 -! - License ---- <br /> Installation will serve: } v Residence" Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel Other.. •------==------------- -------- <br /> Number of living units:---------- ______Number of bedrooms._ ._---- Grinder_._1....._-Lot Size__._ ___ C__..___________________ ___ <br /> A7.'4- :. ------------ ----- <br /> Water Supply: Public System and name____ __ _____________Private ❑ <br /> Character of soil to a depth of 3-feet: ` Scind g Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan``_Ad'obe ❑ Fill, Material..........._If yes, type... ....... <br /> ---------------------- <br /> (Plot plan, showing siie-of-lot;16ti_6fiori of system in relation to wells, buildings, etc. must be.placed on reverse side.) <br /> NEW.fINSTALLATION: (No septic tank :or seepage .pit permitted if public sewer is available within 200 feet,)' i <br /> %.I <br /> PACKAGE TREATMENT SEPTIC TANK [ ] ' ' Size---/Z_da ------------------Liquid Depthr_c_______________�___ <br /> ��� ,.. . Capacity-------------< --- : TYP�--C°zi-------Material-- - ------------'-_No. Compartments----- ---------------------- <br /> Distance to nearest: Well______________ -------------------Foundation----------------------- , --------- <br /> Prop. Line_____ <br /> �. <br /> LEACHING LINE' [ ] No. of Lines------ __________________---Length of each <br /> line----- Length._,,,_? _f->_:________ <br /> 1 I D' Sax.-- ---;._Type Filter Material---- ---Depth Filter Material--:--------- ---------------------------' - <br /> ► Distance,to nearest: Well_'.-----_------_------------Foundation';;ea<_�_____.__.Property Line-____' _______________.__s_...� <br /> SEEPAGE PIT [ ] Depth-----------------Diameter--------::-----------Number-F ---------------------------- .Rock Filled Yes n No❑ <br /> Water Table Depth <br /> , -- •---- - ---. .- f - <br /> I -Distance to nearest: Well------- -- - _Foundation------------------- ----Prop. Line --------- <br /> ---- -f <br /> REPAIR/ADDITION <br /> +' <br /> (Prev:Sanitation Permit#----------------------------- ---------------------- <br /> -Date-----------------"--------=----------�---=-----) <br /> Septic Tank(Specify.Requirements)---------•:-------- ----------- - - -------.?"----i`-;--------------- ---------- <br /> Disposal Fie.ld (Specify Requirements:----.-- --------------------------------- ------------------------------------------------------- ----------I------------ <br /> -------------------------- ----- --"-=------------"-------------- ----------------------------- ---------- -- - --.-:--- --- 3 <br /> -- <br /> i 4 <br /> "{Draw exisfing and required addition on reverse side) <br /> I he'reb certiF that I•have re ared this.application and that the work will be done in accordance with San Joaquin County <br /> Y Y P P <br /> Ordinances, State Laws; and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: T <br /> "I certify that in the performance of:the work for which this permit is issued, -1 shall not employ any person in such manner as <br /> to become subject-to Workman's Compensation' laws.of California."- <br /> Signed-------- <br /> alifornia."_Si ned--_----- <br /> re <br /> --- <br /> ` <br /> _ ----Title- --- ---- ----'------------------- ------By t <br /> (If other than owner) ; <br /> FOR DEP TMENT USE ONLY �. s <br /> APPLICATION ACCEPTED BY_` _ .., ----- --------------------- .--- -------------DATE. - --------------- <br /> DIVISION OF LAND NUMBER-------------- - -- --= _ -=-- -- -: - ---DATE--- ------------------- ----------------------- <br /> ADDITIONAL COMMENTS--- ------------------------------ -------------------------------- <br /> ------------------------------------------------------ ---- -------- -- --- _-------------- ----------- ------------ --------------------------- ---------•- ---- ---- ---------------=------------ <br /> ------------------------------ -- _ _.- ----- - - - - ------- ---------- <br /> Final <br /> --- F <br /> A <br /> Final-ins-inspection b ------------ <br /> EH <br /> Y:.._:__--- -- � �i:� - ------- Date--- --- --- ------ <br /> �' �~ F&5 21677 REV. 7/76 3M <br /> �►+ 13 2e, :, SAN JOAQUIN LOCAL HEALTH .DISTRICT <br />