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r <br /> le 1 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No'.7.. '.. ..tel.._ <br /> Date Issueds.. ........ <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 isting Rules and Regulatio s: <br /> ' �^ A � `u CENSUS TRACT.. ' <br /> _ <br /> OwnerJOB 's NaSme.LOCA� �r._..�jD.'� � ��f � ` _ t <br /> /' " ' --...----'----'- -. .... .............. .. ---- <br /> Phone... r .--�' ---- <br /> Address-.- ; .. ------ f v .... TGA - _ City �� C - --_-- --zi <br /> _ _ p.... --- " <br /> Contractors Name.....-i",_ -..,F,_ =..a.... �A''' ---------•-.---- ----------- -- ----License #- ✓�_ aL..Phone-55 <br /> Z-A <br /> lnstollation will serve:, Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> K. Motel ❑ Other----...................._-----------••-------- �. <br /> Number of:, <br /> f <br /> living units: ..............Number of bedrooms.. ...Garbage Grinder------------Lot Size_------------- .................:.......----- - -- -- <br /> Water Supply: Public System ander"lame.---... .------' -"---"----------------"- -- .......--.--"------.. ... •-------------------- --- ------------- ---'--Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam IX <br /> Hardpan ❑ Adobe ❑ Fill Material-- ---. --..If yes, type.................. ............ <br /> S _ <br /> (Plot plan,.showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.);V <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( } SEPTIC TANK ( ] Size_.._�a!C � ._X' --------------- Liquid Depth..:' Y-��-.....--- <br /> QY' <br /> Capacity✓- ... " TYp �F G . Material No. Compartments t._..... ' QJ <br /> F i i <br /> ,r-u. Foundation_. G?. . ..Prop. Line._ -------------- <br /> Distance . <br /> to nearest: Wel!-:..__ _ ... ..._._.....___.LEACHING LINE [ ] No. of Lines..,.. [ _--Length� �` <br /> f each line,-9_ __� _- Total Length .. a....-`.__.._.._..W <br /> 'fm\ D' Box-�-. _..::Type Filter Materlal.�� a� epth Filter Material....-.-��-!�... .-------'------- ,r:'"................ F <br /> Distance d nearest;Weil__, .��__�._� .".Foundatior 4`��------------ -Property Line..-.6?:>................-.-( <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number--------------------------- --- Rock Filled Yes ❑ No'[:), .. <br /> Water Table Depth",_'-- ------ ;= Rock Size--'-- --- ... ' = <br /> = Distance to"nearest:;Well ------------- ---.....,'.. Foundation-----'-- .........Prop. Line..--- ------------------- ; <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................ . -' Date-------- ..........._.------ -----) <br /> Septic Tank (Specify Requirements)-.................... ,:f ,. '--- -"-'-- <br /> Disposal Field (Specify Requirements):...... .......... . ----­--------­---------- ---------- <br /> I ___ <br /> --------------- - - ................... <br /> ------------- ------------------ ----- <br /> (Draw existing and required addition on reverse side[ i <br /> I hereby Certify that I 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-San,Joaquin Local-Health District;-Home-owner-.or licensed agents <br /> signature,certifies the following: <br /> "I certify1that 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 toWorkman's Compensation-low' s, of California." <br /> 4 <br /> Signed_.._ �. i. �,.r�- -------------._: Owner <br /> BY `........... .......: <br /> ---------- Title ......... -----------_------._...-- ---------------...-- ---------- <br /> { (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... . ... -------------------DATE -- --------- <br /> DIVISION OF LAND NUMBER--- --------- - ----- ' '-- .._..DATE_... ---'--. :..._.... <br /> ADDITIONALCOMMEN -----------------------------------------------------------------------' -----------------------.---------- ----- --------- ------- ---------------- -- - ........... <br /> ......... ------------------ ....._....._'------- <br /> ------ .. <br /> -------------------------`- ---------------- -------- ---- - ._...._ - - -- ------ -' ' <br /> Final-Inspecflon by:----'-.. " -------------------------------------------------------------' -----------Date.------------- ------- ..... " --..... ... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />