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t <br /> FOR OFFICE USE: ✓ FOR OFFICE USE: <br /> APPLICATION FOR SANITATIOM PERMIT <br /> . ................................. -------- (Complete in Triplicate) Permit Na.......- <br /> Date Issued......... <br /> ......................... This Permit Expires 1 Year From Date Issued <br /> t <br /> i 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 complionce.with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION:--....- .----�-, CENSUS TRACT.. <br /> Q �_+ <br /> Owner's Name.--::..:...1.. •4 Phone.. . �.T...... <br /> l N . <br /> Address... ..................... . .. -..�.'.........,.:..._. :' `..-.,_.-.City. - ---- . ....--- . ZiP: ;i <br /> Contractor's Name... ...!�/�RI -- license #��.6..< 1 Phone ..6 - ........ <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----- ----- - ------ --------------------- <br /> Number <br /> -----------•---- --Number of living units:...... ------Number of bedrooms......--3..:_..Garbage Grinder..-.--------Lot ............. •........ . ... .. <br /> Water Supply: Public System and name-----------------. .... .. ------ •-----.Private <br /> I Character of soil to a depth of 3 feet:, Sand [❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> i 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.). C-i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sWisilabie within 200 feet,)PACKAGE TREATMENT ( ] S[ PTIC TANK (XJ Sixe .�� .... Liquid Depth <br /> Capacity _ ----T ef�r�Gs�.- Material..Gdpi.cref" ..No. Compartments__.....�".-----.--•-.------- <br /> t. <br /> Distance to nearest: Well-- -- Sd, --- ..-- F tion....--- ....-.Prop. Line-../------ ...........-- -I <br /> t p� �, <br /> LEACHING LINE I ) No. of Lines .-- --------------- Length of each .Iine.Q..--......--------------- Total Length -------- --......... <br /> . <br /> 'D'Zox._. .Type Filter Material +�� Depth Filter Material------------ ---- ------ 77------ - --- <br /> Di stance,to nearest: WeII. Q. ��.-.-----.Foundation----------------------------Property Line_e!n -. <br /> SEEPAGE PIT € 1 Depth./ ,d, .Diameter.-� Number_.- ------------------- Rock Filled Yes,� No ❑ <br /> WaterTable Depth------------------••------ -- ---- -- --.Rock Size--- -------...--.... ------- .................. <br /> Distance to ------------ <br /> nearest.. Well /S U "--5..-`-----='-----Foundation ------ Prop. Line <br /> ------------- <br /> 7. <br /> �—;jEPAIR/ADDITION (Prev. Sanitation Permit#..-•------------------------------- -- ----------Date----.-.•:---..------------------- ) <br /> Septic Tank (Specify Requirements)-------- ---- ...- -- ----------- <br /> i, <br /> Disposal Field (Specify Requirements)..............I....... ----- . - -------- ...... <br /> ........... -------------•----•-------- - ............ - ----------- ----- ------.. ........_.. <br /> ---------------------------------------------------------- <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that l 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 /> k "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 became subject to r an's Compensation laws of California." <br /> Signed.. .... . .......... .--. c........ ................ ------ --- - -Owner <br /> � R-� <br /> $ � . . �- Title------------------------.--- --.......--...---...--- ------------- -- <br /> Y --------- <br /> other than owner) <br /> F R D PARTM T U E ONLY <br /> APPLICATION ACCEPTED BY----.-.- . .- . - : 1G ....._...._.- <br /> -. . - DATE . 5 .. 7.... <br /> DIVISION OF LAND NUMBER . DATE. <br /> r.,�/ <br /> ADDITIONAL COMMENTS........ . .. ......- - - ..----------------------------------- <br /> -- <br /> ....-_.....-.. <br /> ' 4 ---- ----------- ---•--- --Date. �. � .... <br /> einal Inspection by:..... ----- . -- ----------------- <br /> 24 SAN JOAQUIN LOCAL HEALTH DISTRICT &S 21677 REV. 7/76 aN <br />