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fFOR OFFICE USE: FOR OFFICE USE: <br /> .� APPLICATION FOR SANITATION PERMIT � .�� <br /> ..................... <br /> ---.. -- . . - ­ (Complete in Triplicate) Permit <br /> 4"7/T1 <br /> Date Issued..7: iP.-2f' <br /> ........---------- ............. ............-._. This Permit Expires t 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 Count Ordina ce No. 549 and existing Rules and Regulations: <br /> /114 <br /> JOB ADDRESS/LOCATION.- AlA .�4*"f' - .....-- .410� ----- /. .. . ar_.... CENSUS TRACT^.. <br /> Owner's Name.-- - ......._13aA �•f.4. 9.... -_... . ------•...--- . ---.. ... Phone_./.� .. .- --. <br /> O <br /> Address . i �% '" ? t` >= - -Cit Y - - <br /> ^� ! <br /> Contractor's Name-___---_ _ . ._ `.._. ...-__.License #-_.,.. . ± El�___.Phone_. <br /> Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court F-1Motel ❑ Other---- - ----------------- ---•----- ---------- <br /> Number <br /> --- •--- <br /> Number of living units:....... .__Number of bedrooms_.... Garbage Grinder............Lot Size... .---X - ..... <br /> ---- <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 or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ j SEPTIC TANK (ice ' ize L�.roZ ._.5-- /_ - Depth...--..------- --�_` <br /> Capacity-/&0.0------Type .Material No. Compartmerr s s'� J <br /> r <br /> Distance to nearest: Well------ _... .. -------- --- .....Foundation..../0 ----.-.-- ...Prop. Line-.,Z-----.......... . <br /> LEACHING LINE No. of Lines_- ..............Length of each Total Length . f,7.d._�.................: i <br /> D' Box---- "_T a Filter Material. . e th Filter Material.-_� ¢� ----.----- <br /> YP . p •--- <br /> Distance to nearest: Well.,�L_1`.'�1.---------------Foundation __'Zlo--- .....Property Line.. -------- <br /> SEEPAGE PIT [ Depth--a.6 .....Diameter-3.4._.--------Number__........9 .................. Rock Filled Yes 2j­—No❑ <br /> Water Table Depth......... • ....Rock Size.- -..r2... .---•-.------•-•---------. <br /> Distance to nearest: Well---,,! ---------..---------.......Foundation_,,/.4,0.--- ---------Prop. Line.NJ.-..._.._......._..-..-. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...._----------------------------- ----------- ---Date.....-...-_-...__.._._-__----------.-.-----) <br /> Septic Tank (Specify Requirements)------ --- ------------- <br /> Disposal Field (Specify Requirements)___..._.._. ---------- <br /> ............................ . ... -------------------------------------- -------------- -------------- ................... ----.---- -------------- .............. •---•--- <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 s e t Work n' Cop ensation laws of California." ' <br /> Signed . - - ---� - --y- Owner <br /> - . . ....Title <br /> By........................ <br /> (If other than owner) <br /> ORD ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..... .... --------------•--.--------- DATE .,�--- -� /� -- - ------------ <br /> DIVISION OF LAND NUM R.... ------------------------------------------------------ DATE - <br /> - <br /> ADDITIONAL COMME Sj° ... ..... - .-- ------- <br /> -•-•-----------__ -------- ---------- ----------- ...... ------------------•....-----.------ -----.----...-_...--------- <br /> ..... .-- . <br /> .......................... . <br /> ._.... <br /> Date._. - <br /> Final Inspection b C .0, --- _- ------------------------ 7 <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />