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FOR OFFICE USE: FOR OFFICE USE: <br /> ! APPLICATION FOR SANITATION PERMIT <br /> ------------------ ------------------------------------- �- 90� <br /> {Complete in Triplicate} it No.- _________________ <br /> --------------------------------------------------------- <br /> /s`-7-- <br /> ------------ -Date Issued-Z---------------- <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 /> JOB ADDRESS/LOCATION----';---- _3.3 __ ----�� Q__-- `__S -- 4 ---- 1--.CENSUS TRACT--------------------------------. <br /> ce <br /> Owner's Name - /- ------------- ------------ --------------- ----- ----Phone , -_7 <br /> Address--------------------- - - •J! ._. y... Q .S----/ -- City-_'.4-3 C'fl/0 Zi <br /> �j —j p------------- ------------.------ <br /> - 26hone---- / /e74 - <br /> Contractor's Name_________ dxle��t_____________License #__ <br /> Installation will serve: Residence-Z Apartment House [E•--Commercial [],.,,,Trailer Court ❑ <br /> Motel ❑ Other--, ------------------------------ --------- <br /> Number <br /> ----- -Number of living units:_-,'----I__-----Number of.-.bedrooms_____��Garbage Grinder------------Lot Size______._ �C'�L �._.._..____.�___ <br /> Water Supply; Public System and name---------------1�R,'1�fi�d�-------W-e __-_ Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑' Clay Z Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpans 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 [ ]i SEPTIC TANK J ] Size-------------_—__=___�pZ=_ ` _____4 ' _Liquid Depth _��__-__-____ <br /> Capacity _� �?ype__19,eec_�?_L/Mate�nal_ C�,t1C:R -No/Compartments__.___ -_.______________�__ w <br /> { <br /> , .Distance,to nearest: Well_____._._3.-5�0----------------------Foundation-_/ --------Prop. Line------l___,7C?___--- (� <br /> ' LEACHING LINE [,l. No. of Lines_______.2._____.___:=._.Length of each line-____-__.5-0__1____.___Total Length :_.__._1 U._r>_,.,_--_______-------- <br /> 'D' Box._3--- Filter Material_I,____!_ e th Filter Material-______- __________________.____._ <br /> �/ .;. <br /> Distance to nearest: Well-__.____.TS-0______ r <br /> _--Foundation____=�,-/-�-------------_Proper#y Line--;---.-�------------------, _-. <br /> SEEPAGE PIT [ ] Depth_-_�__Diameter.__ G.______-Number_ <br /> -------------_ Rock Filled Yes?] No ❑ <br /> Water Table Depth-------------------------------------------- ---' --.Rock <br /> t <br /> U : Size.------ .Ot- ----.------------------- <br /> Foundation -- --.Prop. Line--------a-�---`----------Distance to nearest: Well-'----- <br /> a __ <br /> REPAIR/ADDITION dAd <br /> r <br /> (Prey. Sanitation Permit#---------------------------------------------_----Date-----:-:----------------_----------------------] <br /> . - (11 <br /> Septic Tank (Specify Requirements)--------=°-------------------- -------------------------=---------------------------------------------------- ----------- ----- <br /> { Disposal Field (Specify Requirements)__-, ------- -- - ------ --------------------------------------------------------------------------------------- --------------------------------- <br /> --------------------------------------- ---- -7-- -- ------------- ------------------- ------------------------------------------------------------------------------------------ ------- <br /> : <br /> ----------------------------------------.- --- ----------- ------------------------------------------ <br /> (Draw existing and required addition on reverse side) t <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 iertify 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---- --�-J-�-�-~1- - --�r-f�� �------------- _..'Owner <br /> ` F <br /> By- --------------------:----= --------------------------------i------[------------------ ------ Title------ /L--•------------- ------------------------- <br /> �~ ; (If other than owner) ` <br /> FOR DEPARTMENT USE ONLY <br /> ---------DATE _ 1 - `---�---- --- -- ------ -- <br /> APPLICATION ACCEPTED- BY--- ------ - � - ----- ------------------------------- - -------------- ' <br /> DIIASION OF LAND NUMBER--------------=- ---- ---- --------DATE----------------- <br /> rADDITIONAL COMMENTS------------------------ ------ ------------------------------------------------------------------------- ------------------------------------------ <br /> ----- - ---- °`----------------------------- ------- -------------------------------- -- - <br /> --------------------------- ---------------- -------- ---------------------- <br /> Final Inspection by:__� ,- ": =---------------------------------- ------------------------------------Date-fl_ _ _ ---------------- _ <br /> i <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV, 7/76 3M <br />