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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 014 <br /> (Complete in Triplicate) t( it�- Permit No.7..e.7/SS <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 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? .. A ao ....... ..........CENSUS TRACT._ <br /> Owner's Name. ......Phos /�:. 4�1� l?da <br /> .. ........ . ..... ---.... .-- ---- c <br /> . -----....- ------ --------- ------- <br /> Address--------------- ----- - t0-113411-514- 'elf cityv C--- E_ �P.o a Z1p Q�I ---... <br /> - - ------------- - -- ----------------- <br /> Contractor's NameO�.lI„ ....._... .. License <br /> # off -`-- Ph oneC164��GQ-7_----- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ <br /> Motel ❑ Other.................. - •---___-----.---- <br /> Number of living units:..-.- ------Number of bedrooms.--.-.... Garbage Grinder............Lot Size-- ....... . .. . . ......................... <br /> Water Supply: Public System and name....... ------ --------- ------- -------------------------------------------------- ..........................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay ❑ Peat [Im <br /> Sandy Loam [] Clay Loa , fes,, <br /> Hardpan% Adobe Fill Material . ... ....If yes, type-------------.•----------------- VI <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: jNo septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENTr r <br /> [ ] SEPTIC TANK �'�] Size �1.��-- --- - ---------------------------- - Liquid Depth--- -- -- <br /> Capacity./$DV _-.-..Type.-. .....Material_. - ...No. Compartments..... -..........__-...._. <br /> Distance to nearest: Well---_.--/,00-.. - --- ---- ---------Foundation------ Prop. Line-.-i-..--- <br /> op <br /> LEACHING LINE No. of Linesg r <br /> - --, --J----------........Len th of each line...�p�--- - - ---------Total Length . S<Pv...... <br /> .. .......... <br /> 'D' Box...v ..Type Filter Material__r .-.Depth Filter Material_..-1.e....... ...... ...... .... --------- <br /> Distance to nearest: Well..-----, ......_...Foundation------to--.-'#-------..'Property Line-..-S------_._.... _ <br /> SEEPAGE PIT [ ] Depth.......-.. -....Diameter...--.---------.....Number-------------- ---- ------------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth---------------_-_---------- --------------------...-.Rock Size. ------- ........... -- ---- •-------------- <br /> Distance to nearest: Well.---------_- ----------------Foundation...- -.......... .. ......Prop. Line............-..------------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------- --...Date.....------------- -----__- --.------.. -A <br /> Septic Tank (Specify Requirements)...... . ..... . - --- - -----------------•-•- ---------------------............. - -------------- <br /> ---------------- --- ------ <br /> Disposal Field (specify Requirements). .-. ------------ ......-......----------- -- <br /> .---------- <br /> ------------------- ----------------------------- -- ----- - ---- <br /> ... . --•--- .... I-- <br /> (Draw <br /> (Draw existing and required addition on reverse side) <br /> I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Y P P PP <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 subject to Workman's Compensation laws of California." <br /> Signed------- ... ---------- --- ---- ------ ---- ----------- --------------------OwnerBy � <br /> Jam. ..-.. �...... ---------•---------------------•- Title-----r76.2 .`......-.:-----------_--- ...... ---- -- .... <br /> (If other than owner) <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- .. --....._DATE. .... . ..a_g..7..�.... . .......... . <br /> DIVISION OF LAND NUMBER. DATE_.. ..-- <br /> ADDITIONAL COMMENTS......... ... ........... ------ --------------- ------ ----- - -- --... - . <br /> -•---------- -------- --------------------------------------........ . ................................. - ..------------------------- ------------.---------- -------- -----------.--............. ... <br /> ------ <br /> ----- ---------------- <br /> - ------ <br /> ------------------------------- -•---------- --- -- ---------- <br /> - <br /> Date <br /> Final Inspection by:....- .... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas_21677 REV. 7/76 3M <br />