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FOR OFFICE USE.W. FOR OFFICE USE: <br /> 41 <br /> ­ M- 11 APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------- -------- (Complete in Triplicate) Permit No.--7-7--XI7 <br /> ------ ------ ---------------- ------------ Date Issued--- 2 <br /> ...........F/-- 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 /> 540 N. Anteros <br /> JOBADDRESS/LOCATION----------------------- --------- - --- ----- - -------------------------------------------------CENSUS TRACT------------------------------ <br /> Owner's <br /> RACT----- -------------------------- <br /> Owner's Name------------------We--Roots--- -----------------------------------------------------------------------------------------------Phone---------------- --------------------- <br /> 540 N. Anteros Stockton <br /> Address------------------------- - - - - ------------ - ------ ------------- --------------City----------------------------- ---------------Zip----------------------------- <br /> Contractor's <br /> --------------zip------------------------------ <br /> Contractor's Name-------- --------Rota-R-oot-er-S-wer-Ser-----------------------------License #---271539------------Phone--4.6-5-26-1-6.-------------- <br /> Installation will serve: Residence E] Apartment House Commercial ❑ Trailer Court El <br /> Motel E] Other----- -------------------------------- --- <br /> 7o by 300' <br /> 1 3 . w <br /> Garbage Grind - -s <br /> Number of living units:--- ------------Number of bedrooms---- .. _____Lot Size____________'__________________________________._________ <br /> - <br /> Water Supply: Public System and name---------------------------------------------------------------------------------------------------:-------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand [] Silt E] Clay F-1 Peat 0 Sandy Loam E] Clay Loam El <br /> Hardpan F-1 Adobe Fill Material-P=q------If yes,type______-_---.____-___________ <br /> (Plot <br /> ype-------------------------------- <br /> (Plot plan, showing ?size of lot, location of system in relation to wens, 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 Size-__-_____--_____________________________-_____.-.____Liquid Depth.-------------------------- <br /> Capacity----------------- ---Type-----------------------Material--------------------------No. Compartments--------------------------------1 <br /> Distance <br /> ompartments-------------------------------- <br /> Distance to nearest: Well_____-_-___.--__-._______ -------------Foundation___. _______-Prop. Line.___.-_----------------- <br /> LEACHING <br /> ine.------ ------------------ <br /> LEACHING LINE No. of Lines-----------------------------Length of each line.__-._-_____ -_____.Total Length----------- ---------------------------- <br /> -D-Bbx---------Typ6-Filter-MdteeiaI---------- ___Depth Filter Material___ --------------------------------------------------- <br /> Distance to nearest: Well----------------------------Foundation------------------------------Property' Nine________________________-_______- <br /> SEEPAGE <br /> fine----------------------------------- <br /> SEEPAGE PIT --Depth----------------Diameter--------------------Number-------------------------------- R6ck Filled Yes E] No IV <br /> WaterTable Depth---------------------------------------------------- ----Rock Size------------------------------------------------- <br /> Distance to nearest: Well------------------------------------- -----Foundation--------------------------Prop. Line-------------------------- <br /> REPAIR/ADDITION (Prev-.-Sanitation Permit#-------------------------------------------I--------Date----------------- ----- <br /> ---------------- ------ <br /> - <br /> ----------------------- ------------------------------- ----------------------------- <br /> Septic Tank (Specify Req,uiF49ff�&nt4-.,.—------------------- -------------------- -------- ------- <br /> Disposal Field (Specify Requirements)..-------------------- add 40' of leach line and 1-33" by 2�, pit ---------------- <br /> --- - - --------------------------------------------- ---------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------ ----------------------------------------------------------------------------------------- ------------------------ ----------------------------- <br /> (Dr"aw existing and required addition on reverse side) <br /> I hereby certify that-'4-have prepared.-this application and that the work will be done in accordance with Son Joaquin County <br /> Ordinances, State Laws, and Rule's, 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------- -------------- ------- <br /> ---------------- ------------------------ --------------Owner <br /> Estimator <br /> ------------- ---------------------- <br /> By-------- --------------------------------------------------------Title---- - <br /> (If <br /> -------------- ---------------------Title---- -(If other tliqn owner) <br /> ,,FOk DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -------------------------------DATE ----------------------------------------------------- ------------------- <br /> DIVISIONOF LAND NUMBER.----Z-, - - ------ - ----------------------------------------------------------------------.__.__-__DATE___.____._________________________ <br /> ADDITIONAL <br /> --------DATE---------- ------------------------ ------------ <br /> ADDITIONALCOMMTq...... ----------------I----------------------------------------------------------------------------------------------------------------------------------------- <br /> r -- - <br /> ---------- ---4L-- ----- ------------------------------------------------------- - <br /> ------------------------------------------------------------------------- <br /> / 0 ----- - ------------- <br /> -----------------:----------- ---------- ----- -- - ---------I---------------------------------------------------------------------------------------------------------------- ------------ <br /> --------------- -------------- <br /> ------------------------------------------ ----- ------ ---------------------------------------------------------------------------------- ------ -- <br /> - <br /> -- - ----------------------- <br /> Final Inspection by:------ ---- ------ ------ -------------------- ------------------------ -----Date <br /> EH 13 24 F&S 216f <br /> JOAQUIN LOCAL HEALTH DISTRICT _05�7/76 3M <br />