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m <br /> FOR OFFICE USE: FOR OFFICE-USE: <br /> APPLICATION FOR SANITAVION PERMIT <br /> --------------------------------------------------------- <br /> \� (Complete in Triplicate) Permit <br /> --------------------------------------------------------- <br /> Date Issued--_37 4 <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-----�? Q -- ----- _ - ------- --------- ------------------------------------------AW <br /> D , CENSUS TRACT <br /> Owner's Name.......... � e ------ � Phone---�3t 0G- Z1.2 0g- <br /> Address------ �'A'J'�e.- ------------------------------city <br /> - Zip - <br /> ---------------------(--�---------------------- -- <br /> Contractor's Name__ ____ Alk)_/�_.-_Se,t_____________License #-3o__�Z-ZL____Phone_,:.��_1__�.3 3 <br /> Installation will serve: Residence Pq-*' Apartment House ❑ Commercial ❑ Trailer Court ❑ -\" <br /> Motel ❑ Other----------------------------- ---------------- <br /> Number <br /> ------- - -Number of living units:----------------Number of bedrooms---7_-----Garbage Grinder------------Lot Size___® _ <br /> Water Supply: Public System and name___________________.__..__.____________...__ __--__Private �. <br /> -------------------------------------------------------------------- <br /> ____ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ]r-./ 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 [ j SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth-_________________._._.. <br /> Capacity- ----------Type____..________________Material--------------------------No. Compartments-----------------------------------d <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 /> Distance to nearest: Well--------.-------------------Foundation----------------------------Property Line___________________________----. <br /> SEEPAGE PIT [ ] Depth.-------.-------Diameter---------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth-------------------- -----------------------------------Rock Size----- <br /> to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line______________.____._.. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date---------------------------------------------.) <br /> SepticTank (Specify Requirements)-------------------------- -------------------- ---- ------------------------------------ ----------------------------------------- -------- <br /> Disposal Field(Specify Requirements) - 7 �-� - - /.�..� " - 7` ......t ------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <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----t .•------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---- -----------G?7y- -------- -------------------DATE -- - - ------ <br /> DIVISIONOF LAND NUMBER_---_--------_-------------------------------------- --- ------- ------------------------------------.DATE--------------------- -------------------------- <br /> ADDITIONAL <br /> ---------------------- --ADDITIONAL COMMENTS-------------- ----------------------------------------------------------------------------------------------------------------------------------------- -------------. <br /> -------------- ----------------------------------------- ------------ --- - --------------------------------------------------------------------------------- --------- ----------- <br /> ------------------------------------------------- --•-- --- -- ------ -- ------------------------- ------------- ------------------------------------ <br /> Final Inspection by:------------------ ------ ---- --- Date--------- <br /> - - -- ---------- -- ---- -- <br /> E" 13 24 SAN JOAQUIN LOC HEALTH DISTRICT F&s 21677 REV. 7/76 3M <br />