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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ --- -------- - ----------- ----•--•-- <br /> Permit No.}7 <br /> (Complete in Triplicate) .`�- �- .---.-- <br /> Date Issued{5:.-/..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 /> JOB ADDRESS/LOCATION....`....................f�� rI .... - - ...---..--.CENSUS TRACT.�✓�-. <br /> Owner's Name - -GC_ '. ........ -/.. <br /> Phone <br /> Address----------- <br /> 3_�-. ._......... x..1.1 --N----- .----City-- Zips" <br /> l/ <br /> Contractor's Name..... / `.f- ----- �.(�1'7=� License # 6-J � _..Phone <br /> Installation will,serve: Residence Apartment House 0 Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--.. ....... ....................... <br /> Number of living units:.......... ....Number of bedrooms............Garbage Grinder------------Lot Size----.---- ----- - -- ..----.---------:---...--- <br /> Water Supply: Public System and name---- -------------- -------- ---------------------------------------------._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, 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 - ------ Liquid Depth----=-------- <br /> --- -- -- <br /> [ ) Size -----.... -�------------•-----•-•--- -- <br /> Capacity--- ----- ------ ----Type--•--•----------------.Material-------------__.. -..-No, Compartments--------------------------------- <br /> Distance to nearest: Well-_-.....- ---------- - .....Foundation---------- - ---- - -- - Prop. Line---------..-.-......_--� <br /> LEACHING LINE [ ] No, of Lines..-.-.._-_-_--------------Length of each line.......-------....-...........Total Length - .-.------- <br /> 'D' Box...-- .-....Type Filter Material........ .. ........Depth Filter Material.------ -------.---..-.---------------------.--- -...... <br /> Distanc&to nearest: Well_-----_-------..........Foundation---------------.... Property Line.......-.....-....-------- ----. - <br /> SEEPAGE PIT [ ) Depth................Diameter.............--......Number...----------------------------- Rock Filled Yes ❑ No❑ . <br /> Water Table Depth---------------- -•------ ........ ---- ...-.Rock Size...--...-- -- <br /> Distance to nearest: Well--------------------------------------------.Foundation............-.............Prop. Line-------------.--- -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------- ------ ---------------Date-------•..----........------------------------) <br /> Septic Tank (Specify Requirements)...................................... ........... <br /> -------- - .................. <br /> DisposalFie (Specify Requirements)--- ......... --.--- <br /> -------- =--------- <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 shalt not employ any person in such manner as <br /> to become 'subject to Workman's Compensation laws of California." <br /> Sign d_-- -.----. Owner <br /> ------ <br /> ByA <br /> Title.... <br /> (If other than o ner) <br /> FO DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY,------ - -.6,44---------------------------- - _DATE .--.. --- - - ---�-- f��---- - <br /> DIVISION OF LAND NUMBER.--...--. DATE. ..... ........... <br /> ADDITIONAL COMMENTS--..................... ------ ----- --- <br /> .......... <br /> -------•----------------- ---------.-. - ....... ------------- J-- -------.... ---------- i <br /> Inspecfion by;..... ........---- ----- -------------------------------- <br /> alpate. ,j~/�5. r <br /> --24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 Rev..7/76 3M <br /> r� I <br />