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f <br /> FOR OFFICE USE: FOR OFFICE USE: <br />'> APPLICATION FOR SANITATION PERMIT <br /> F _____________ <br /> �®z S <br /> J� (Complete in Triplicate) Permit No.�-.- .__.___ <br /> ------------- 1 I <br /> �/ Date Issued_._��._-.X� <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/LOC' J N---. - ------- 3 Q O_ . % f� --------------------- <br /> Ow <br /> - --.CENSUS TRACT----------------------------- - <br /> G Owner's Name � ----- U-----------'--�-----------------------------Phone--------------------------------- <br /> -Y 5,�7 <br /> Address. <br /> -- ----- ------Phone--------------------------------- <br /> Address. �'� ------City i --------------Zip-------------------------= <br /> Contractor's Name------ _ -J__ __ _ _ . <br /> ------License .#..._ 2 .ZPhone <br /> Installation will'serve: Residence Apartment House.❑ � Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------' =---------------------- <br /> Number of living units:-----l.__'------Number.of,bedrooms_.___ Garbage'Grinder------------Lot,Size__._-. r ----------- <br /> Water Supply: Public System and name <br /> :. i <br /> ------: - =---------- ,- ---------- _ ----------------------------------------,_=_Private ❑ <br /> Character of soil to a de Hard an feet: Adobe Silt Material ;Peat-❑---Sanc{y.Loam ❑ - Clay Loam ❑ <br /> p ❑ ❑ .Clay ❑ <br /> p ❑ + ` <br /> If yes, type_ <br /> (Plofi 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 sevver.is available within 200 feet,j <br /> 3 <br /> i • <br /> ��PACKAGE TREATMENT SEPTICTANK Size�___ ____,. <br /> _r__.X� _ivs� <br /> _ <br /> - ' L;` uid_ <br /> Depth <br /> . --_-_--`-------.-_--_--_--.--_ <br /> -- <br /> .-- <br /> ialCapacity- -- --=Type- atererCompartments---- ------------- <br /> FoDistance to nearest: Well <br /> .�'� i� � __ <br /> po.gLie -- eto l ._ - '.___.Total Len th.__ ____________LEACHING LINEr <br /> X -� T pe Filter Matera - Dep} 'Filter Mate ------------------ <br /> j I <br /> ` <br /> i <br /> .Distance,to nearest: WeIL:�.JF t'Foundation.___:/67��_^.___.Property Line------------ <br /> -----------_____ <br /> SEEPAGE PIT h.ZDiameter_____ ''�Num6'er3__:.__. ___ <br /> -----=:--- �''4_-- Rock Filled Yes No <br /> Water Table:Depth-----------Mll--/---`--------------------- ------Rock Sze -1 / -X- --l--------`-- - <br /> F Distance!to nearest: Well:_ _____ ,le4' .__._.._ Foundation-----IQZ� ..Prop. Line__S__ ______ ___ <br /> REPAIR/ADDITION (Prev.'Sanitation Permit#_______-__.______ Date ---------------------- <br /> Septic Tank (Specify Requirements)---- -- -- ----- ---- ------------------------------------------ -' ---------:=---------------=------- -------------- :--: --------- <br /> Disposal Field(Specify Requirements):-- ------ - -- ------------------------ - = <br /> ----------------------------- ------ ---- ----- ------------------ <br /> M <br /> -------------------------------------------------------------- ---------------------------------- ----------------- ------------ ---- <br /> ------- - -- --- - <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 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 /> "[ cern that in the � <br /> certify pei-fotmance 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-1aws of California." . <br /> Signed--------=----- = Owner <br /> I k <br /> By------------------------ ---- ------- ?-----~ .. .. _Title _ - --- -------- t <br /> ' � i <br /> - <br /> E {If other than`owner) <br /> FOR DEPARTMENT USE ONLY } M <br /> APPLICATION ACCEPTED. BY ;07 ------------------- R------ ----- ---DATE. ° ✓ <br /> DIVISION OF LAND NUMBER---------------------------------------- <br /> --- ---------------------­ DATE--------=- ------- ------- <br /> ADDITIONALCOMMENTS - =-------------------=------ ---------- -----=----------•------------- -----'------------- ---------------------------- ---. <br /> _____________________________________________________'____________.___--------_---_--_..________---- <br /> _ ____________________________________ ----- _ _ __ ---------------------------------------- _.----- <br /> Final Inspection b __________ ______________Date-' . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT / { 77 REV. 7/76 3M <br />