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a <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> { M .. Permit No..7.�-_.�3-S <br /> �+ (Complete in Triplicate) -�• , <br /> l c <br /> Date <br /> ................. --••••••-- .... ................ Y` This Permit Expires ] 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 madein compliance'with County Ordinance No. 549 and existing Rules and Regulations: <br /> J08 ADDRESS/LOCAT N.....: I ®..:... :...-... ........................CENSUS TRACT <br /> .. . . ................................. <br /> Owner's Name...... .- I .�- <br /> ` .. - .. ................ -----Phone- -/-- ...... <br /> r Zi <br /> Address--.. Ci ----...... <br /> Contractor's Name.................... <br /> ------------- -- --- License 4_444.35F,94.-_.Phorie :..... <br /> Installation will serve: Residence Apartment House ❑. Commercial ❑ Trailer Court ❑ <br /> t Motel ❑' Other_- .--.... <br /> Number of living units:.----. ------Numb er of bedrooms-..+,..Garbage Qrinder------------Lot Size.__6.0.. .1z0.........:...................-_ <br /> { <br /> Water Supply: Public System and name F�..................- - ....... --••--=•-•--- -----....-..-:.-.... - - -- --------------Private El <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay 0 Peat ❑ Sandy 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 TANK = Liquid Depth----=--------_.--.-_.-� <br /> [ ] Size.------ �------------------------------•--•- -- ---- - - <br /> Capacity....-- --------- Type---------------- ------Material---.Foundatio .....No. Compartments...------------------------------- I <br /> Distance to nearest: Well-=---------------------_-_....-. . - ' <br /> - ---- n----- -- - -------------Prop. Line--------------�--------- <br /> LEACHING LINE { ] No. of Lines..._-.'_.-'-----------------Length of each line:----------------•------------Total Length .................---------..--......... <br /> 'D' BOX........-...Type Filter Material....................Depth Filter Material----------------------------..------------_---------............ ' <br /> Distance to nearest: Well------------------------------Foundation----.__----- ] <br /> r <br /> --•-------- - ..Property Line_..-•----• ----- ----- ---------- <br /> SEEPAGE PIT { ] Depth----------------Diameter.-------------------Number---.---------------------------- 'f� Rock Filled Yes ❑ No ❑ <br /> Water Table De,Pth--------------------------------------------------..-.-,--.Rock-Size------ - - ---- - - ---- <br /> Distance to nearest: Well-..........................................Foundation--------------------------Prop. Line.............--....---.----. <br /> r <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------------...........Date------:--......................--------------- <br /> ) <br /> Septic Tank (Specify Requirements)..... . . ................ - ---------------- ....�, --- .................. <br /> Disposal Field (Specify Requirements).... !-�. 4007�. :- , �! • ! '........................ --....---.-- <br /> -t� -- , -- --- ----------------------.� .......... ------- ----- - --. <br /> N <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 Sart Joaquin Local Health District, Horne owner or licensed agents t <br /> signature certifies the following: I k <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 j <br /> to become subject et Wotkma ' Compinsatiorn laws of California." a <br /> Signed----- ---. ... ---�.. . .. t. --------------------Owner <br /> 8y.............•------- --------- <br /> - TitleE <br /> (if other than owner) <br /> i + I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY , -----....�. - - --- - ------ - -------------------------------------DATE....S-d- .J ------- <br /> DIVISION OF LAND NUMBER. .. y „�. :DATE------------------- <br /> - -------------------------------------------------- ------- --- <br /> ADDITIONALCOMMENTS................ ........... .......................................................... .-I.......................... -- -- .._... <br /> ------------------ -------- --------- ----------------------------------------------------------------- ---------------------------------------- ------------------------------------------ - - <br /> ..-----•-------------------------------- ---------- = --------------- <br /> ------------- ----•--------•-•---• �..- . . ------------••------------------------------------•- --•-•-------------------^ - - <br /> - -- ---------- <br /> Final Inspection 6y:.... <br /> -------------------------------------------------------------------------------•- .......-..Date... .' sSJ� <br /> -.._. . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fns 21677 Rev. 7l76 3M <br /> r <br />