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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----- ------------------ --------- ---------------------- <br /> (Complete in Triplicate) Permit No___ _ -_ o <br /> ------------------- ti � 77 <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 o 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: m <br /> pp CENSUS TRACT------------------- <br /> JOB ADDRESS/LOC lON_ __-... _C-.____--- _ <br /> Owner's Name _ `�-""--- ------------- -Phone--- ` --.-- ---- <br /> Address `r G- Y �`�;-------- ----- City e `------------------- ZAP = <br /> Contractor's Name.. --Ss��---- c< - �� 'y--- ---a-- --`---------------License # 3 Phone W{I <br /> Installation will server Residence (Apartment House.❑ .Commercial ❑ Trailer Court ❑ <br /> . . .p Motel rl Other---',- = = '---------------- ----' = ! [ <br /> Number of living units:._'____ _______Number of..bedrooms_.___dr__.._Garba a Grindar_. -.___---.Lot Size____=.--_ =1 �___:.__ - ___._.._. ci <br /> g �C <br /> Water Supply: Public System and name----=------------------------------------_ .: ---------------------Private <br /> Character of soil to a depth of 3`feet: Sand Q Silt E] Clay E] Peat EDSandy Loam E] Clay Loam E_] i <br /> Hardpan [ Adobe.0 Fill Materia <br /> l._.-_?___._If yes, type__________________________----- <br /> i <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 t k,or seepage 'pit permhied if public`s wer is available within 200 feet,] <br /> PACKAGE TREATMENT- [ ] ' SEPTIC TANK-[* " ' .'-Size - Liquid Depth._ <br /> Capacity ='; 'Tye--------------------- -Material---- --=----=--:------ -- No. Compartments ---- -- <br /> -------------------------- <br /> Distance.to nea�es�W.ell._------_-----;-------------------_--- --Foundation--------------_-------_---Prop. Line-------=----------------- <br /> , � - <br /> t --------------------------------------- <br /> LEACHING LINE [ ] No. of Lines---------------- f edch�lme..— ,___.-:-- Total Length .. <br /> •' . <br /> i :D' Box_.'-----_.._Type Filter Material _____________------Depth Filter Material---------------------------------------------------------------------- <br /> J <br /> ______-__------,-------_____. <br /> Distance to nearest: WeII_____________ "Foundation.___._____ ! <br /> Property Line._!-_____--- <br /> SEEPAGE PIT [ ] Depth------------ -_Diameter..------;___.__.---Number-------------____---_^__._____ Rock Filled Yes❑ No <br /> Water Table:Depth-----------= - Rock Size: ------- --------------- <br /> ----------------------- # <br /> Distance to nearest:�Well- -- ---------- --------------_------Foundation---•------------,--____--.Prop. Line_"?_.:---------------`-_-. <br /> REPAIR/ADDITION (Prev:Sanitation-Permit _-----=--=------ _Date.......� S <br /> ___.______._____ <br /> Septic -------------------------------------------- <br /> Disposal. <br /> -]` <br /> Tank (Specify Requirements)._-_:---- cc-- --- --------- ---------------------------------------------------------------------------=-------=----- ------- <br /> Disposal.Field (Specify Requirements)`_- - ------ --------------------------------------- <br /> -- <br /> ---------- -- ----------- k <br /> -- � - <br /> --- ----------2S ' <br /> - - --- -- - - - <br /> --------- ---- --------I--- ------------- <br /> J <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.-clone -in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the Sari Joaquin Local Health District, Horne owner or licensed agents <br /> signature certifies the following: <br /> f "I certify that in the performance of:the,woW for which this permit is <br /> 'Issued; .l shall not4m0loy any person in such manner as <br /> to become subject to Workman's Compensation, laws of. California. ' <br /> Signed--------=--- ---------------- - - - --:.------_Owner <br /> '.Title_, _ _ ` `"-------- { <br /> } By_------------------------ ---- <br /> (If other than owner) . <br /> -FOR DEPARTMENT USE ONLY <br /> --- <br /> F APPLICATION ACCEPTED BY- __- -------- DATE <br /> DIVISIONOF LAND NUMBER- ---------------- -------------- -------------------- -------------DATE------ ----------------- - ---- -- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS------------ ----- <br /> - --------------------------=-------------- --•-------------------- -------------------- --------------------------------- - ------------ <br /> --------------------------=------------------- ------ ----- ---------- --------------------------- -- ---------------------- ---------- <br /> ------------ <br /> ------------ ------ <br /> ---- ------=--- - <br /> Final Inspection by.--==- = _ � Date � r�/� <br /> FH !3 24 SAN JOAQUFos 21677 REV. 7/76 3M <br /> I LOCAL HEALTH DISTRICT <br />