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c-- <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION rOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit Nol..%-1, . - <br /> Date Issued.-q`.lig <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 incompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. .... r� ..... <br /> • • CENSUS TRACT.. <br /> Owner's Name....ti_. ---------- --------- ---------"----___ .................Phone................ -------------- <br /> Address.... ...... <br /> - �.� ------ ,: Cir ---------.. . ..zi .. <br /> y P = .....-.-_.. <br /> Contractor's Name..:. ... ....... License # � fPhone... <br /> �- <br /> Installation will serve; Residence Apartment House ❑ Commercial [] Trailer Court ❑ <br /> Motel ❑ Other-- I-----.. ------ <br /> Number of living units:.......l.__---Number of bedrooms.. .....Garbage Grinder---___.-.Lot Size----- l ' , . �.- _.... . <br /> Water Supply: Public System and name-------- =----------------- -• ---------------------- - --- - -- ---- ....-.Privat <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 /> (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 [ ] Size ... _-f Yy / ........Liquid Depth....--- ------------- <br /> 9 <br /> Capacity./I ea----Type-, ------ Material----e-----------No. Compartments..- <br /> ----------------- <br /> Distance to nearest: Well----...�.. ... ......I. :........Foundation----/0.............Prop. Line...- r3.0..--.....-I <br /> LEACHING LINE [ ] No. of Lines _' .------------..__-.Len th of each line..... . Total Length' <br /> D' Box__., ..- .Type Filter Material......../..Jol Depth Filter Material. .f.�-------------------------- ------------Distance to nearest: Well---------------------.. ...``FFo��undation---------------------.......Property Line-----.--------..-----------SEEPAGE PIT [ ] Depth-p—C._ ..._._Diameter.. .-.......Number.....�r--------------------- Rock Filled Yes L� No <br /> Water Table Depth..---•:-:---_ -- _."..'"r .......... ....Rock Size.----" --------- <br /> Distance to nearest,'Well-....._..".__ I.... .-----Foundation.-. .� . Pro Line........_-------------RI»PAIR/ADDITION (Prev. Sanitatiori Permit#-----------i----._ . .. _.------Date <br /> -_-.- ) <br /> Septic Tank (Specify.Requirements)------ ------• • ............ ------ <br /> Disposal <br /> .....Dis osal Field (Specify Re uirements ................. <br /> ---------- ------------ -------------------- ..:, <br /> -------------------------------------------- <br /> k ' ...... <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 County <br /> Ordinances, State Laws,t and Rules and Regulations of }he GSan Joaquin Local Health District. Rome owner or licensed agents <br /> signature certifies the following: ` k 'r <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 as <br /> to become subject to Workman's Compensation laws of kCalifornia." t <br /> Signed = �- <br /> Otwner--- ----- ------- <br /> By- <br /> ----- <br /> By• --- -- <br /> i <br /> --- ---- ................ ......... Title.-----"---- ........ - "---"------ ........ # <br /> (If other than owner) I <br /> I FOR;DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY......N.!WJJU__. , _­­­­­---------- --- -------I. .................. .DATE ....... ......� ................... <br /> DIVISION OF LAND NUMBER .........................I.................------------------------- ---- ---- DATE.---- ------------ ...-- ------------ <br /> ADDITIONAL <br /> - ._._.ADDITIONAL COMMENTS ..... ..................:."----------------------------.....-----.... ------ --------------"-- -----.....-----------------------... .._ <br /> -------------- --------------- ................................. ------------- - -- -------------------------- ------ ------------ -------------------- ......... ...... !€ <br /> . .. ..... <br /> ------------ -- q. ®® ..' . <br /> Final Inspection by:. - . --- "- ---- --------------------------------- - <br /> -------------------•-- ------------------------ \=�p1� .4..-. <br /> EH 13 24 - - F$S 21677 REV. 7/76 3M <br /> N <br /> SAJOAQUIN LOCAL HEALTH DISTRICT <br />