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FOR OFFICE USE: FOR OFFICE USE: <br /> C APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .. __.._ <br /> --- ---------------------------- <br /> I �{f <br /> aZ <br /> This Permit Expires 1 Year From Date Issued Date issued__.= .=_?_e <br /> i J <br /> Application is hereby made to the San Joaquin Local Health Distriet-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- --- <br /> ` -_-----' ---------- ----=-=-.CEN TRACT <br /> SUS ---------- --------_---- --- <br /> Owner`s Name------- <br /> = -- - - ------------ <br /> t ;-- ---- - ------------------ _ .Phone. --- <br /> Address. t d i' City_ . . <br /> C <br /> Contractor's Ndme- •ayt p ---- --- dv <br /> ----- -------License #__3 1� Phone-,-- ---------- <br /> 4 <br /> Installation will se-rve: Residence ❑- Apartment House. Commercial ❑ raider Court ❑ <br /> Motel [] Other------- <br /> =<=-'- - ' <br /> Number of living units-------- "------Number.of bedrooms------ <br /> ------Garbage Grinder---------__Lot Size_____ __ ___________ .....-.__.•.______.__.!___ i <br /> 1 : <br /> Water Supply: Plubli6 System"and name _-__. . -- <br /> ----- ---- . <br /> EJ <br /> Character of soil to p depth of 3 feet: " Sand ❑ 'Silt E] Clay Peat E]_ Sandy Loam ❑ Clay Loam E] - Private <br /> p [ Adobe'❑ Eill'Materialof es typ "�- --:�- — T <br /> (Plot plan, showing size of lot, location of sy'sfer:n_in_relati0d to".wells, bui[dings,:etc. must be placed on reverse side.) I <br /> NEW INSTALLATION: (No septic tank"or seepage pit permitted if public sewer is'available within 200 feet,) I <br /> PACKAGE TREATMENT " t' iP f <br /> 1 SEPTIC TANK '[ �0 5iz$_zV'� - x `5 ,,�LL <br /> { .✓ [� )N _----Liquid Depth T------- ------- <br /> ltdact GP _: Compartments c <br /> Dist6nce'to.nearest: Well-------- -----5�_ -- ,_- <br /> T e `— <br /> -r' P ty yp. - Material- -�_- - No. <br /> ( / s._ w' Foundation-- -10�_-Prop. Line_.,-_ .------ i <br /> LEACHING LINEY No, of Lines_ _ _ g r <br /> t Len th.of each line.____-___ �i <br /> f � Total Length.----- - A <br /> D Box...^_._.Type Filter NlateriaL_`� _ ,----•Depth Filter Material.____--_1 __1i___________------------------------ <br /> ----------- <br /> I <br /> _ ► <br /> - --- --- --- <br /> + G+ <br /> Distance to nbarest,: Well <br /> Foundations Property Line------ ' <br /> SEEPAGE PIT [� Depth.__ _ Diamete.r'-__ _ _N.umber_____' 7 R II <br /> i _ ! . .. ed L� N <br /> ((p4 -------------1---4— <br /> Rock F1 Yes o ❑ .9:4 <br /> d J -------------------- <br /> - / ____-- _-___________ <br /> J Water Table `Depth________ ___ _ <br /> r i l '; Rock Size -, .3 ii <br /> REPAIR/ADDITION (Prev. istance to nearest:Well :`____ . -- <br /> FM, 1 ----Foundation-------��- -----..Pro Line-------S-t• --- --- <br /> ( Sanitation Permit*__! "---------------------------------Date F <br /> Septic Tank (Specify,Requirements)...= ,___. ---------- <br /> -------------------------------------------------- <br /> Disposal Field (Specify Requirements)______________________ ____________ " <br /> -I ----------------------------------I--- . ---------- - - --------------------------------- ---------- - ------ <br /> --------------- - <br /> 1 (Draw existing and required addifiode) 414 <br /> n on reverse side) <br /> - ' <br /> I hereby certify thof,l have prepared this application and that the work will be done iw accordance with- San Joaquin County <br /> Ordinances,' State Cows, and Rules and Regulations of the San Joaquin Local Health'District. Home owner or licensed agents <br /> signature certifies th� following: <br /> "! certify #hat 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 io Workman's Compensation' laws of California." <br /> Signed ; 4vn <br /> ------ _ <br /> BY; = Title--- <br /> (ifI <br /> ---------------- <br /> --------- ----- ---- -- -- --other than owner <br /> FOR,DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-__._ _ <br /> --------------`--------- DATE ---- <br /> .r'� & '_ <br /> DIVISION OF LAND NUMBER. ---.----- DATE. <br /> ----- --- <br /> ADDITIONAL COMMENTS------------ <br /> ---------- ----------l <br /> J <br /> -------------------------------------- ------------------------------------------------------------------ ------------ <br /> ------------------------------ ---- <br /> -------------------------------------------------- <br /> Final Inspection by:--- - ----- ------ <br /> .� tic=z. ----------Date--- -- r <br /> EH 13 24 U <br /> SAN JOAQUI LOCAL HEALTH DISTRICT •fss 21677 PM 7/76 3M <br />