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yFOR OFFICE USE:2 /APPLICATION <br /> FOR OFFICE USE: <br /> 00/ FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> Date lssuecllj �,:;7-7,$?`� <br /> --••••-•------------ ------- - ..... ------ - .- This Permit Expires 1 Year Front Date Issued <br /> 1 <br /> Application is hereby made to.the San Joaquin Local Health District far a permit to construct and.i4tall the work herein described. <br /> This application is made in compliance/with County Ord0•na ce.No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATION.--.:... ., `� ­­---------....CENSUS TRACT.................._._.-- . <br /> Owner's Name.... . . ---Phone •....................... <br /> 1 <br /> Cit Zip Address------- <br /> Contractor's <br /> - -- <br /> Contractor's <br /> Name._,.-- . Gr License #- 40.17{.7�. <br /> eI.....Phan 4. <br /> fr . <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E]otel ❑ Other........................ ................ <br /> Number of living units:_..... .----------Number of bedrooms._ .Garbo e Grinder...........-Lot Size._. 24 <br /> ..-- <br /> Water Supply: Public System and name......------------ - e' - --------------------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 /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc. must be place&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 TANKSize Liquid Depth................ ...... -� <br /> ( ] - �- - -- •• --••-- - : <br /> Capacity_ t'> <br /> P Y ----- --------Type -•- - --`.... ......Material---------- ------•----....No. Compartments.------.:................ <br /> -- -- -Q- <br /> Distance to nearest: Well.-.................. ...... .... .........Foundation.-.- Prop. Line....... <br /> ----------------- <br /> LEACHING LINE f ] No. of Lines ------ ---------------------Length of each line----------------------------- Total Length .. .---------- <br /> 'D' Box...- -- . Type Filter Material........ ... Depth Filter Material.. .- -- ------ ..---.......------...._.......... .-.-.. <br /> i <br /> Distance to nearest: Well------------- ---- -- Foundation.-.._- -.------ Property Line----------------------.-............ <br /> SEEPAGE PIT ( ] Depth...... ... ....Diameter------------- ......Number---....-----------._---......_.. Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth------------------------------- -----------------_----.Rock Size----- ---.. .-------------------------------- -- <br /> Distance to nearest: Well------------------------------------ ........Foundation..........................Prop. Line......- --- ---_ <br /> REPAIR/ADDITION {Prev. Sanitation Permit#...............T ----------- - <br /> T»� -Date....._. ) <br /> Septic Tank (Specify Requirements)---- -- -oLaDQ-:. <br /> i.... <br /> Disposal Field {Specify Requirements)--.---..., i _ �_ ................_-.-•.. <br /> Y . <br /> ........................................................- --- ------------.....----------- .....................---................................-- ......-- - I <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, 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 Compensation laws of California." <br /> Signed........ .. ....... .. ------------_------ ------------------------------------Owner ; <br /> BY------- .... ------------- ....................... Title.............-.............................. -------- ......... <br /> (If other than o 'ner) <br /> F DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY------ ------------------------------------DATE ...( .-? ..7�.-- ...... . <br /> DIVISION OF LAND NUMBER... ..... ............ ...DATE......_._.-------- ........ --.............. <br /> ADDITIONAL COMMENTS-------.. --- - -- ----- --•----- ! <br /> --------------------- ---- - --- ---- --------- -------------- - ------------------------------ _ - <br /> -------- ....--•- ----------- --------- --------.------•-----.....-- <br /> ------ - ; <br /> ---- ---------•------------ -----...-------------------------•------------------ <br /> ---- -- <br /> Final Inspection by:..... ..Date....... <br /> .. <br /> Fos 21677 Rev <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT , 7/76 Sen <br />