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I] <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> Permit No. -� (Complete in Triplicate) �9 /a,S-Ff <br /> Date Issued-/d..-y-7,5?'� <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 /> /� `-{uL . <br /> JOB ADDRE55/LOCATiO ---� 1 � `!J�- -------t�-°='------- --- ------- "�------------------ ---- _------ -.CENSUS TRACT - -- ---------- <br /> ��r%r �r,L _ Phone------------------------ �. <br /> Owner's Name c-� ------ ----- <br /> c <br /> Address - f ---------------------------------City =` f ------Zip----------------- -- ----- <br /> Contractor's Name--- --- d�-tom C License #___3 7 Z2-Phone--- ----- ------- - -I------. <br /> al <br /> Installation will serve: Residence � Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> IMotel ❑ Other------------------------------------------------ <br /> Number <br /> ---------------------- ----------------------Number of living units:------- __-..Number of bedrooms-......Garbage Grinder---- ------Lot Size___ _________________ _____ ________ <br /> Water Supply: Public System and name-------------------- -: ---------=.--------------------------------- --= 1.C• Cw. -----Private E]Character of soil to a depth of 3'feet: Sand ❑ Silt❑ Clay ' Peat E] Sandy Loam [� Clay Loam ❑ i <br /> g <br /> Hardpan E] Adobe E] —Fill Material_-'_.•--....If yes, type-------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to.wel.ls,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--------------------- <br /> -----------------------------------------Liquid Depth- <br /> Capacity--------------------Type----'------------------Material---` ---=------ ----------No. Compartments---------------------------=------ +,l <br /> J <br /> Distance to nearest:.Well:._,..-- ------=-----------------------Foundation- ----- ------- -------Prop. Line--------------------------- <br /> LEACHING LINE [ ] No. of.Lines---------------- ------------.Length of each lino.-----------------------------Total Length ---------------------------------; <br /> 'D' Box------------Type Filter Material-------------------- Depth Filter Material-------------------.------------------------------------------- <br /> Distanceto nearest: Well-----`----''------`---_.Foundation------------------------- ----------.Property Line.- ------ ---------------. - ---C <br /> - -: s. -_: ; ,. is -� 1 <br /> SEEPAGE PIT [ ] Depth----------------Diameter---------------------Number-------------------------------- Rock Filled Yes'❑ No❑ <br /> Water Table,Depth---------------------------------------------------- --Rock S�ize------------------------------------------------ <br /> N <br /> Distance to nearest: Well-------------------------------------------.Foundation---------------------- .Prop. Line--.------------------- i <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--::_.--'-------------------------------------------Date---------------------------.-._.-------------_) II <br /> Septic Tank (Specify Requirements)--------------------------------- - ] <br /> ---j--------------- I - ----------------------- ----_. . <br /> Disposal F' (Specify Requirements)- --J. �c 1 `` ` ---------------------------------------------- - - <br /> ma -- `' ----------------- ------ <br /> -------------------- <br /> ---- T <br /> ............................................................................................. - . <br /> {Draw existing and required addition on reverse side) M �� <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, 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 peirmit'is issued, 1 shall not employ any person in such manner as <br /> to become subject to.Workman's Compensationlaws of California." <br /> Signed- --------- --- -- - ---- --------- --------- Owner <br /> ---- �. -:rz'�� -C Title -E _----------------- ------------------- <br /> By- i <br /> ` <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTE ------ ----- ------------- ------ � ---. --- 2 -l- <br /> DIVISION OF LAND NUMBER -------------------------- ------------------------------------------------ -----------------DATE.,-------------- -- ----- <br /> ADDITIONALCOMMENTS---------------------------------------------------- -------------------------------------- - -------------------------------------------- --------------------'------- <br /> -------------------------=---------------------------------------------------------------------------- •---------------------------------------- ------------ --------------------------- <br /> ------=----------- ---------------- --- --- - ---------- -----------------------------=------------------------------------------- ----------------------- <br /> Final Inspection by: --------�'----- <br /> - --------------------------------------------------Date..-2- J <br /> ------ - --- --------------------------------- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />