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FOR OFFICE USE: - FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> `-------------------------------------------------------- <br /> (Complete in Triplicate) Permit No.��_�ao9 <br /> ---------------- - -- - <br /> --­------------- --- --- ----k This Permit Expires 1 Year From Date Issued Date Issued_1/_-/S-�g <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-_-3__ __7-------------------------- 7T1 Atom.._.-R_�i_______.___CENSUS TRACT-------------------------------- <br /> Owner's Name----k- e----------- ---- - --------------- ----- ------------------- ---------------------------------------------.Phone---�3_t�7--;� C <br /> Address----------------------- i _ ---------------------------------------CitY 5e —/ /0 117 - <br /> s ---------- <br /> Contractor's Name_____ <br /> --------------------License #�6 <br /> ___14-101- <br /> _ _ _ +����'_}�________________ <br /> Installation will serve: Residence/❑ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-_( iu= -- -- <br /> s� j ys t <br /> Number of living units:_..1__.-__--Number of bedrooms------------Garbage Grinder. _ ._. - Lot Size -(7_% l ____. _________ _ __________ - <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------------ 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: (Na septic tank or seepage pit permitted if public sewer is available within 200 feet,) w <br /> PACKAGE TREATMENT ( J SEPTIC TANK [ ] Size___-T_ ��s'- '- -------------------------Liquid Depth57�_;(__________________ w <br /> Capacity/.Z6 -------Type, - Mgterial----------------- ------N4a. Compartments------A---------- ------------ -C <br /> Distance to nearest:,Well---c7�__ __________ _ ______--_lounc tion -1------------------Prop. Line_ 0_ <br /> LEACHING LINE [ ] No. of Lines_______________________:Length of each line----'____-----------------Total Length---------------------------------------- <br /> 'D' <br /> -_____ ________.____-___'D' Box_1--------Type Filter Materialfa�r� _ eptFi Filter Mlafierial___ -------_._._.__ <br /> Distance to nearest: Well__/�0-________________Foundation----------------------------Property Line__.._____-__________________-_-_. <br /> SEEPAGE PIT [ ] Det �' <br /> p h��._______Diameter__�,�__ �___Number._____/______________.____ Rock Filled Yes X No ❑lti� <br /> WaterTable Depth---------------------------------------------------------Rock Size----------------------------------------------- 0 <br /> Distance to nearest: Well------------ ------------------------------Foundation--------------------------Prop. Line________________._________ <br /> REPAIR/ADDITION (Prev. Sanitation Permit _. - _ ____ ___ __________=___.Date------ -- `- --------------- <br /> Septic Tank (Specify Requirements) ``� ---- '--------- - -'--------------------------------- ------------ ------ <br /> Disposal Field (Specify Requirements).._ _ r ' <br /> -------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------------- <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 permitis issued,_ I shall not employ any person in such manner as <br /> to become subject to orkman's:Compensation laws of California." <br /> Signed ------- ------------------------------------------------ , <br /> BY--------- ' ------------------------------------------Title----------------------------- --------------------- '---- -------------- <br /> --if other than owner) <br /> FOR DEPAYMENT USE ONLY <br /> APPLICATION ACCEPTED BY------ --- ------------------------- ------- --- DATE. /--tel- - ---------- <br /> DIVISION OF LAND NUMBER.------ :.- ------� -------------- -- ------------------ ------------------ -------------------DATE----------- --- <br /> ADDITIONALCOMMENTS------ ----- - -----------------------------------------------------L--------- ------ --------------- -------- ---------------------------------- <br /> ---------------------------------------------------------- ------------- ---------------------------------------------------------------------------------------------------------------------------- ------------ <br /> ---------------------------------------------------------------------- <br /> --------- ------ -------------- --- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------- - - - <br /> � `------ -------------Date----------- <br /> ----------------------- <br /> - ------------- <br /> Final Inspection bY�-------��---`f�- -- -------- ----- - ----------------------------------------------- �'� J� �� <br /> EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&s 21677 REV. 776 3M <br />