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FOR OFFICE USE: FOR OFFICE <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No,....7-:7 .�.`. <br /> lv' a ':77r' <br /> Date Issued.......:.--.--- , <br /> A7�- -� ----- ---_ This Permit Expires t 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 /> JOB ADDRESS/L ATION.... .. .... �.... <br /> - - - - --- -------.CENSUS TRACT....,.....-------- -- ....:.--- <br /> Owner's Name... ----- <br /> . . - - -•-� �...� .-- - -----•-- - - ---- .:-- ------Phone /C— Y8/—?,� <br /> Address....... <br /> city-. <br /> i <br /> ty- P <br /> Contractor's Name.---... -- -...................License 43.6�FFSL......Phone...:.'0-0-4a:..-.._- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> /Motel E] Other....................... <br />--Number of living units;---l.---------Number of,bedrooms...s5.....Garbage Grinder------------ Size.-. �.. ..:.................. .. <br /> Water Supply: Public System and name------- ------------------------............... Private' ` <br /> 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 /> a <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 /> -.�. 1 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK > Size.. _.Sx.�B.�..:.... ................Liquid Depth-..:7.--..........._,...- <br /> i Capacity. C�..._..T - <br /> YP �..Material_.(. - :No. Compartments--.--•--. r.-. <br /> Distance to nearest: Well_A06...-------- -------------------Found"ation../d.. __._......_..Prop. Line- -, - <br /> LEACHING LINE P4 :- �o"of Lines'.:. :._ ,'_.4 :....Len th of each line_ � ` <br /> g ----�Q -.91�_Total Cength ...�ZD... ....... ...... <br /> t/ .�} <br /> D' Box-.------....Type Filter Material..!./ia Q� Depth Filter Material........................................ <br /> Distance to nearest: Well,/D �. 2 <br /> ��....._._.Foundp�tion.-O.0.................Property Line._.---2 ....... <br /> SEEPAGE PIT [�' Depth.._GtIS.____Diameter....-....._....___Number. ------.... .- Rock Filled Yes ' No ; <br /> *Ii .i <br /> Water Table Depth-------16.4-- --••-•--- - ------ ..................Rock Size--e ,�C, =--•---. <br /> Distance to nearest: Well.-,lr�.-----------------------------Foundation..Z.7-D.�...-.....Prop. Line_,T! b!""'!,:.....-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------:---------_-..--------.-------- Date....-----------.-----.---------.--------------1 <br /> Septic Tank (Specify Requirements).............................. -- ----------------------- ---------............----------..------------------ .......... <br /> Disposal Field (Specify Requirements)......................= ------------ --------------'•-- ------------------------- • -------------------------------- ------- <br /> ------------------------ -----------------------=------------------------------------ -------.....---.....----------•-.. <br /> -------------------------- ------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: 1 <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 as <br /> to become sub' to Warkm s Co pensatian laws of California." <br /> Signed......... ?' "r <br /> ....... � .......... .........-------- .-........ _.. Owner <br /> By......................... - _ _.7itle <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.,.+.. --- -. . ... ....-._,DATE...... .................... > <br /> DIVISION OF LAND NUMBER�.... ..... .:.......... 31f-4Z ............................. = DATE....-- --:--------------------- - --------- ... <br /> ADDITIONAL COMMENTS..__. 1;Y - ----•-••------ - -------- ------------ <br /> --------------- --•- ----- -- <br /> �n <br /> . <br /> Final Inspection by:.. ..........V ­ Date. - i <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M <br /> t <br />