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FOR OFFICE USE: aw FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT , <br /> ---- ----- -- --------=-- -------------------- <br /> (Complete in Triplicate) Permit <br /> Date Issued. <br /> --------------------------------------------------------- This Permit Expires I'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--------- 0 ____- f `-------- -_/T ----------- -- ------CENSUS TRACT- -__,-- _ _-------- <br /> --- •- <br /> Owner's Name -------------- -------------- ---------------------- -------------------------- •--- <br /> Address - <br /> ----------- ----------------------------------------- ------- ----- -- - r--�O�/---------------------Zip---- ---f <br /> Contractor's Name------- ....... -------�------------ ------License <br /> Installation will serve: Residenceffl Apartment House.[] Commercial ❑. Trailer Court ❑ <br /> Motel 0-:.-Other--- ---------- -- --- --------------------- <br /> Number <br /> ------ ----- --- <br /> Number of living units:-..... _ Number of bedraoms__: '.__-Garbo a 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 2g Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill Material.-.---,--7---If yes,type---.---------------------------- <br /> (Plot <br /> _-_ _:_ _--:. -___---.-_(Plot plan, showing 'size of lot, location of system'in relation to wells, buildings',etc, must-be'placed on reverse side.) <br /> NEIN INSTALLATION: (No septic tank or seepage pit,permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.--r---------------- ---------------------------------Liquid-Depth--------------------- 7-- <br /> !Capacity 1446 Type �e CAsr p <br /> NtiateriaL-_- <_ ----No. Compartments - --------------------- <br /> Distance <br /> ------- ---Distance to nearest: Well----------jet?_'*----------------------Foundation-------/a_1------__.Prop. Line_- ep,-_ <br /> LEACHING LINE [ ] No. of Lines__ - .,.. ___...__.Len th of each line o OtO _--_ ___-__-Totat Length _,"*�___ __ _ __ ____ ______ <br /> 'D' Box----I-----Type Filter Material: O� ------Depth Filter Material----------------- <br /> Distance to nearest: Well----- ----------- anon-::_ y____--------Property Llne ._3"i?--- <br /> SEEPAGE PIT [ ) Depth-- _-_---Diameter-----------_ ---_..NumbeF- - -- ------ ----- ------ Rock Filled Yes❑ No <br /> WaterTable Depth-- -- -----------------------------------------'-- -Rock Size.----- ----­--------- ------- --------- <br /> Distance to nearest:Well----------------------------- -- ------Foundation---------*­--------------Prop. Line---------- <br /> REPAIR/ADDITION <br /> -_ ---- -REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------ _,_;Date ----------- --------------------------------- <br /> Septic <br /> __ - ----_-_ - --- --_Septic Tank (Specify Requirements)------- ---- ---- ----- -- ----- -------- _ ._ <br /> Disposal Field (Specify Requirements)------------- ------------------ ----- ------ ------I ----- - ---- --------------------—------_ -- - --- ---- <br /> -•--- --- ------------------------ -------- ----- ----- ----------- - - -- --------- <br /> ----------------------------------- -- ------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that) have prepared this application and that the work wilt`be done in accordance with San Joaquin County , <br /> Ordinances,. State Laws, and Rules';and Regulations of the Sian Joaquin Local Health Diatrfct,.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-manter;as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed------ -----------'T---oAt-------'----- ----d-Ni ------Owner, <br /> -----------------------------------Title------------ ---- ----- --- --------- <br /> - (I er than owner) <br /> FOR Op <br /> ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ---- - - --- --------- ------ --- -- -----------------BATE.-----?-/--lQ - <br /> DIVISION OF LAND NUMBER:_-------------_-:---•___-- DATE-./ <br /> ADDITIONAL COMMENTS--- � Zvyrfj� L� d` 0 <br /> --- � Z~ --- <br /> -------------• ---- - <br /> ----------------------------------------------- <br /> -- -- -- <br /> Final Inspection b -----------------------------------Date- --._ - 1 _-- ---:---. <br /> P Y <br /> �- - <br /> ----- - ------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 Rev.7/76 3M <br />