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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> n Yt" 1 -. - <br /> (Complete in Triplicate) Permit No... .._ -- --------- <br /> zt- <br /> Gl­o Date Issued.:�`_.:7r.-7 <br /> -- This Permit,Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> r This application is made.in compliance with County Ordlinarye No. 549 and existinrq,Rules d Regulations: <br /> JOB ADDRESS/LOCATION_.... i- - <br /> _....... CENSUS TRACT <br /> y <br /> Owner's Name........ . ..... .................. ............ .. ......-Phone <br /> ' <br /> Address-........ ..:�•t7- - �- --------- Ci � ----- ---- -----...---- ----- <br /> , <br /> - - --- - ---- - ------- city--------------------------- -------- Zip--.: <br /> Contractor?-s-Name_-------- ----- -- .' -- _ ------ -----.License #-.-- - - -Phone. <br /> T < <br /> Instal l;btiori'wilI serve: Residence , Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------------- -- - <br /> Number of living units;.. .....Number of bedrooms......1R...Garbage Grinder------------Lot Size.-._.- <br /> Water Supply: Public System and name...---- ---------------- .. Private ❑ <br /> I Character of soil to a depth of 3 feet: Sand❑ Silt[], _ClayPeat y. ❑ y ❑ <br /> [� ❑-_,Sand 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 [ ] SEPTIC TANKSize..... <br /> ------------------- <br /> -------------- <br /> -Liquid Depth..:................... . <br /> [ ) <br /> Capacsity--.-..... Type---------- ------------Material--------- ....: :..:No. Compartments."---........------.- <br /> Distant to nearest: Well_:..--11............. .... . ...... ... Foundation....__.... . .............Prop. Line-_._..--.-- ----.- <br /> LEACHING LINE [ ] No. of Lines......._-------------- .Length of each line._......................... <br /> . Total Length -- ------- --------- <br /> D' Box............Type Filter Material- 14S <br /> Filter Material....._..._.................... - <br /> Distance to nearest: Well-----------------.... -__-.Foundation.... ---------------------.-Property Line.------------------------ <br /> . <br /> 0�1 <br /> SEEPAGE PITp !. <br /> [ ) De th._..___.._.._Diameter.-- Number.... -• Rock Filled Yes ❑ No <br /> ;,' Water Table Depth---------- ------------- ---------- Size Size_..------.-..- <br /> Distance to nearest: Well...................... ...---------_.Foundation.-. -----. ...- .....Prop. Line...--------.--_.-- -.._..._. <br /> ' REPAIR/ADDITION (Prev. Sanitation Permit#..'............. _:........ ' T :Date: - �J' <br /> Septic Tank (Specify Requirementsj.._..: _.. <br /> E -•--------=- <br /> Disposal Field ISnecify Requirements)- <br /> .. . <br /> ------------------ ----------- .......... -------- ----------------- ------- ------ ---------------------------------- ­ ­........................ ...­­........... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application"!and that the work will be done in accordance with San Joaquin County [ <br /> Ordinances, State Laws, and Rules and RegulatioA► 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----- .... Owner 1 <br /> By................ -Title............................ <br /> If <br /> JeWrtha wne-) - ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...... .............._---....__. _...._.. 7 <br /> - --------- - -------------- -------DATE ....----- ---- -- _ .. -.....�-- --- <br /> ADDITIONAL COMMENTS.......... -- <br /> DIVISION OF LAND NUMBER............... -------DATE.....................---------------------.. . .. <br /> ................. <br /> ---------------I.......................- ----- .. _ f ------------ P <br /> = ��" - ._.A _.__..i'��--------------- -----------------•- •------------- ---------------•-•--.-...._.__------_--------------... <br /> _... <br /> --------------- ----------- ------._.._.. ... ........- <br /> Final Inspeciion . ...by:... . . s' <br /> - -- - ------- --- --Date.. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s'2167 EV. 7/76 3M <br />