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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --4kllzi----- ------- ------------ <br /> lComplete in Triplicate) Permit No.7./?_._:_d.9-_ <br /> ------------------------------------------------ <br /> . - Date Issued-/__"3 <br /> ._----------I----------------- ---------------------_-- This Permit Expires'.1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for permit t 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/LOCATION -; .: '-- ---------- -- - �--- -- ---- CENSUS TRACT -----------------..----------- <br /> s <br /> Owner's Name- ------ Phone <br /> Address-- - City Zip <br /> — <br /> Contractor's Name ' � . �_- . --------------License #- -7/7/---Phone- __ � �'. .. <br /> Installation will serve: Wesidence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> ._ .. - 4-- Motel Other_ <br /> ----------- <br /> ------------ <br /> Number <br /> --Number of.living units:--':-,-a------Number of..bedrooms--J--Garbage Grinder-.--_ -__Lot Size----_ ------------ ------ <br /> Water <br /> ---Water Supply: Public Systemand'name----------------------- ------ --------- ------------------------------ -- _ --- -- ---- - -- ----------------------------------Private ` <br /> Character of soil to a depth-of 3 feet: Sand ❑ -gilt-E] Pat❑ Sandy Loam ❑ Clay Loam _ r <br /> Hardpan ❑ ' Adobe❑ Y s, type-----------------=-------------- <br /> (Plot plan, showing size of lot, location of system in relation to•wells, buildings,'etc. must be placed on reverse side.) t <br /> NEW INSTALLATION: '(No-septic tank or _seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT -[ ] SEPTIC TANK [`] F Size:.: f _..` ... : _- ___Liquid D"epth._. :_:.__._____t___t3 l <br /> r' Type / ial _:...:No. Compartments----_Ca acitY _ te <br /> s <br /> (. ]Distance,to nearest:.Well----.- _ __= _--'--,---- Foundation--_.-��--- _-_____,_-.Prop Line_---:^ <br /> LEACHING LINE:. [. ] .Na, of,Lines_'_ ' Length. of.each line------ - ._:.._._ Total Length __� ,,, __ ; ' <br /> t;. <br /> .D' Box _ , ype Filter Material'_-- _-- � ----Depth Filter Material_.--_ --- _ _ --- <br /> :Distance.to nearest: Wel!-------- _- Foundation.... '__ Property Line___________________ ____.--_- <br /> SEEPAGE PIT [ ] Depth., .___.D,iametee _ - - Number k...'y�.�..___ ock Filled Yes. No ❑ n <br /> „. : <br /> ' Water Table Depth..-- -----------------------------------------------.--- Rock Size-'-- t -' ---- ----------- ` <br /> Distance.to nearest: Weld.?'.... -`-------------------------Foundation-------------------__--_-.Prop. Line----------------------- --. <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#.:i -"----- -----------------------------------Date---------------------------------------------- <br /> Septic <br /> .----------------- _----------------------Septic Tank (Specify Requirements}----=----- - -- ----- ------- - ------------------=-- <br /> Disposal Field (Specify Requirements)------- --•------------ -----"-------------------------------------- ---------=-------------------------- --- -- <br /> , -, <br /> ---: =-------------= --------- ------ -------------------------------- ----------------.-------.---------------------------- <br /> ------------------------------ -------- -------------------------------------- - ----------------------------------- -- -- ----------------- - = -------:------=------- --- <br /> [Draw existing anck_-required addition on reverse side) <br /> hereby certify that I have-prepared this app[ica`tion and`that:the work will be done'in'accordance with San Joaquin County, i <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: <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 Damp son on Jaws of Cali orni <br /> Signed t- --------- -- _ <br /> -,O ner <br /> t <br /> BY ------ -- Title ---- !�'"� ------------------------- -------- - } <br /> ifVth tha owner) <br /> , <br /> f <br /> F R DEP MENT•.0 ONLY° . <br /> APPLICATION ACCEPTED BY_- ------------- <br /> �Cp - DATE 3 <br /> DIVISION OF LAND NUMBER---------------------------- --------------- <br /> ------------ ------------------------------------- ----------- - -----DATE--------------------------------------------T <br /> ADDITIONAL COMMENTS---- = 3 ?�� ... r <br /> -- <br /> ,n <br /> -------- ----- -------- --------- - - -------- --------- K+ ------up��� : :: ��= �� - � / = <br /> -------------______-----------________________----------------------------------------------------- --------------------------- -----------: ..._.__-. -T._.___________________________________________________ __ _____j_.--_._.____.__________.._.__.______-_-._.-______.._._.__._._.._______-._-_-____--..---'------------__-___ __ _ ______..__.._.___- ---__ <br /> �..._._ ..._ r.._.. i <br /> Final Inspection•by:-` �� —. _ _.. . - �_ Date ----------------- <br /> - -.EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&s 21677 REV.-7/76-3M <br />