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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ ?� is� <br /> (Complete in Triplicate) Permit o.... . ............. <br /> This Permit Expires 1 Year From Date Issued Date Issued, :J-7�7 <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 ON.... —` <br /> S6 <br /> ----_-----------_---CENSUS TRAC .._....... q .......... <br /> Owner's Name---- ..-. f./ f. �'4-__.. ._ Phone" �7 <br /> of t ._._ �- -- _. y. �Address--_---------- --- <br /> ----------�9 - <br /> .` <br /> `' --- <br /> Contractor's N .Phone..? <br /> --- ------.---.--- <br /> Installation will serve: Residence] Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------ --------------------------------------- <br /> Number <br /> --------- -------------------- -----Number of living units:..... .------.Number of b drooms.!Z_....Garbage Grinder------:.....Lot .. ----- -------- - --� <br /> Water Sdpply: Public System and name_..._ (A4TG��_..._..--__........................................__--.-----.---------..------.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat E] Sandy Loam El Clay Loam Q <br /> Hardpan ❑ Adobeo 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 t- SEPTIC TANK [ ] Size ..-...-.Liquid Depth......... _ .._...- <br /> Capacity.AZn O - --.Type&. � Material_ il ._m _No. Com artments-.�................: <br /> --- ---- <br /> _ _ _/ � _ s <br /> Distance to nearest: Well.. _/ _. _. ... .._I- _Foundation .I_ - _.._.__. .. Prop. Line©, <br /> LEACHING LINE gQ No. of Lines_ __ oZ'...............Lengt of each line....�5-- --_Total Length Q�. <br /> --- ------------- ----------- <br /> rr <br /> 'D' Box_ -F-5-.Type Filter Material. .&X>2,��.Depth- FiltEr-Material-. __A ........ ......... ....._ <br /> Distance to nearest: Well_1(1 �-__ ----- Foundations.....................Property Line. .._-._-_--_.._....___..-.__._. <br /> SEEPAGE PIT V] Depth-o�.._._Diameter .__...Number.� _o2----------------------- Rock Filled Yeses No❑ <br /> i X <br /> Water Table Depth................. _-•---- . .....-------------------Rock Size.. <br /> Distance to nearest: Well...... IV67.......................... Foundation---...__._.__-- _. --....Prop. Line-----._..._.__....._..__._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....._............................ ...............Date................. ------.-_--.----] <br /> Septic Tank (Specify Requirements)----- .. ------ •---•-----------_.............. ------------- • --_------ ----- <br /> Disposal Field (Specify Requirements)_--__.......:....... . ---- ---------• <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 /> "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 subje o Workman's C nsation laws of California." <br /> Signed--- -- ---- ------ . -- ......... -- ....... -------._..-Owner <br /> .......... . ...... _... ---- --- ----- Title-------------------- _ <br /> (If h an o er) <br /> FO PA MENT jJSE ON Y <br /> APPLICATION ACCEPTED BY - ^- -- --- DATE _` 2`:..7.lr- -- .._... <br /> OF LAND NUMBS -... -- - _.. DATE... - ---------------- <br /> ---------- <br /> DIVISION <br /> ADDITIONAL COMMENTS.... ----------------------------------- -. --------.._...._._......- <br /> --------------------------------........------ ------- . <br /> ------------------------ ._.. ... .. <br /> ....................................... ....... ...... .. ...... ...... ......... 1-/­/ <br /> .-_._:...._..-.____ ------------ ----- <br /> ... ---------- <br /> Final Inspection by: --------------------------------- Date... 7 - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />