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FOR OFFICE USE: FOR OFFICE USE: <br /> j APPLICATION FOR SANITATION PERMIT <br /> ----------------- ------ -------- ---- 7.2-- o <br /> (Complete in Triplicate) Permit No._____ ____ <br /> -----------------Ae�-A­_� <br /> Date Issued___------ <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------------------------------ --------------------------------------------­--____ ___-CENSUS.TRACT-------------------------- <br /> Owner's <br /> _.___: _____336 <br /> Owner's Name--- -----------------I - -'--- ------Phone- --- -- - <br /> . <br /> Address---�/__1 °1q---- � !-� `� /C ---------------------CitY �� ---� ---- Zip--- � 0 <br /> Cl <br /> Contractor's Name ___ � ---------------------------------l -_---License <br /> - Ph <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ } <br /> Motel ] -, Other-_._.__ M <br /> j_t__. Number of bedrooms-___' Garb° e Grinder ?°j _Lot.Size_ -k <br /> Nulmber of living.units:-_ _ g j <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,_8 <br /> fHardpan Q Adobe ❑ i Fill Material__ ______If yes, type______ _____- <br /> (Plot plan, showing size of lot, location of system iIn relation toywells, 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 1° Size:__ 4`-)" '©'� "' 4- <br /> - -- -- - Liquid Depth. ------ <br /> 1 <br /> 100 <br /> Capacity_/ _:____ Typep-,- Material ___ No. Compartments _ <br /> Distance to.nearest: Well),___�-A� -_ 'Foundation � _ -. ____-_____Prop. Line. �'-------------- <br /> - <br /> _ _.__.__- <br /> --- <br /> Len th of each line °_____;Total Length ._� ------------------ <br /> LEACHING LINE [�J_ No. of Lines---------A-_ '_ g �r-- -_ <br /> 'D' Box.•'�fseType Filter Material_�,.e _-__Depth' Iter Material_-__ /� _,___.__ -------------------- -_ -------- <br /> LEACHING <br /> Distance to nearest.. Well.__,1-3a'4 :.____Foundation__16 '-- - -__Property <br /> 9 -. rLined�----------------------- <br /> SEEPAGE <br /> -- ___j___ _ __N-. <br /> SEEPAGE PIT, Depth_ � ____ ___ Rock Filled Yes <br /> __Diameter____ --.Number_ _ --------- <br /> WaterDepth <br /> "y <br /> Table Depth- - Q"- -------- ----------- - --- --:---Rock Size-_ �� -- - ------ <br /> r Distance to;neare'st:f Well t`: A.__�' ____ Foundation J____ ___ .Prop. Line__ _________ __ __:__-. <br /> REPAIR/ADDITION (Prev. Sanitation:Permit#---------__ - :Date___----- ---. __) F <br /> Septic Tank (Specify Requirements) - -------- <br /> Disposal Field (Specify Requirements)__ F '____ _________- <br /> - -- --- ---- -- - - ' - <br /> ------ ----- -- ---- ------- ----------------------------- --- ------------------ <br /> x <br /> ----- 1`• �� -- <br /> t (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,,Iiceq!ed.agents <br /> signature certifies the following: -n <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 beco a`subject 1p Wor man's Compensation laws.of California." - <br /> Signed_ _ -JP ----------------------------Owner <br /> BY --------- ------------ -- -------- ---------------- [------ --- Title ---------------------------------------------------------- <br /> (If <br /> ----- ------------. ,------------------------------- <br /> r <br /> - <br /> (If other than'owner) <br /> FOR'DEPARTMENT USE ONLY 4 f <br /> APPLICATION ACCEPTED BY-- 54 �c l-�'!' -, - DATE.- "=~I-p-_- 7--------------------- <br /> -------------------- <br /> DIVISION OF LAND NUMBER-----------------------------------'------- ------------------------- ------------------------------------DATE..------------------ ----------------------- <br /> ADDITIONAL COMMENTS ____ ---------------------r__ -------------------------------- -------------____ _____ ___ _____ -- <br /> --- ---- - ---- - ---- ---- -- <br /> ------ ------ -- --- - -- --------------------- --------------------------------------------- ------ -- -- <br /> --7EHFinal Inspection by: -- ----------------- ti--- --------- ------------------ -- �/( - Date---------- ----------- <br /> ----------------------- <br /> EH <br /> 13 24r F&5 21677 REV. 7176 3M <br /> ,� SAN�JQAQUIN LOCAL HEALTH- RICT <br />