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FOR OFFICE USE: FOR OFFICE USE. \ <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ --------------------------- - `�� ' ;7-------------- <br /> Date <br /> - 5 <br /> (Complete in Triplicate) Permit No.__7___' ------ -- <br /> Date Issued_-_ '_________ <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-_- ��__�c'_e � _____ c"=� �_z _' '-- ___CENSUS TRACT______ <br /> '7 -- -------- ---- - ----- <br /> Owner's Name_ '_L`.�YL -/ "' _CEA-------------------- --- ------ ------ ------- -- -- ----- <br /> ....._--Phone-------------------------------------- <br /> Address-- <br /> ------------- <br /> ----- -------- ------------ <br /> Address- v -: <br /> ' r 1='= <br /> City- <br /> < <br /> � Zip------------------------------ <br /> --- <br /> --- -- <br /> _ o _____Contractor's Name_ L - t_, /------ _-- _____LicensefZ <br /> Installation will serve: Residence 2r- Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------------------------- ---------- <br /> Number of living units-----/---------Number of bedrooms--__---Garbage Grinder------------Lot Size---Z f' --_ ___-- <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 orge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [seep Size_- _________________Liquid Depth _/-----______ <br /> Capacity- /1 C' e TYPe ( c crr.a-Material '. =----------No. Compartments------ -------------- <br /> C <br /> Distance to nearest: Well----- <br /> _'rL'__J''t___________Foundation____ _ _ _!____ _Prop. Line_______'_ ----------- <br /> LEACHING <br /> _________©LEACHING LINE [!] No. of Lines_.____-__3--------------- Length of each line-------LI_C'_J_4--------Total Length ----0_CI-C-_____________ <br /> 'D' Box-----1------Type Filter Material------- _____Depth Filter Material--------- --------------------------------------- <br /> Distance to <br /> ______________________________Distanceto nearest: Well-----�__�G:_�-C_____Foundation--------�_�-_�_�__t_Property Line-------- -________________ <br /> SEEPAGE PIT [tf Depth___-,-2,r,//fDiameter----- ` -_`_'__Number---------.,------------------ Rock Filled Yes I- No ❑ <br /> 1 <br /> Water Table Depth -----I--�'-r- --'�--------; --- ----- ------ .�1.----Rock Size V--`---X- ---------------- ------- <br /> Distance to nearest: Well---------1__ _- ____(----------------Foundation------)-t-4-7-f.Prop. 1^Line_____- _ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____________________________________________Date________________________________________) I <br /> SepticTank (Specify Requirements)---- -------------------- -------------------------------------------------------------------------------------------------------------------- --------- <br /> Disposal Field (Specify Requirements)--------- ---------- ------------------------------------------------------------------------------------------------------------------- -------- <br /> ----------------------------------------------------------------------------------------------------- -------- ---------------------------------------------------------------------------------------------- <br /> - - - - - -------- ------ - ------------ - <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> _ / _�_�� z c= -----------Title - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------C- --------- ---------------------------------------------------------DATE l ---------------------- <br /> DIVISIONOF LAND NUMBER ---------------------------- -------------------------------------------------------------------- DATE ----------------------------------------------- <br /> ADDITIONAL COMMENTS----------------- --------------------- ---------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------- --------------------- <br /> ---- --- -- ----- - --- --------------------------------------- --------------------------------------------- <br /> J/_ _/ ---------------------- <br /> Final Inspection by:---- ------ - ------------------------------ ----------------------------------------------------------Date--- --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />