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- FOR OFFICE USE: FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT ���� q <br /> ------------------------------------ Permit No. <br /> (Complete in Triplicate) <br /> ------------------------------------------- <br /> - Date Issued-y-S'_7--- <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 witch/County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION--------- ----'T._y-�d- //rlL%--//A V&_10 7 ---.CENSUS TRACT----------------------- - - <br /> Owner's Name.--- ---- ----------------------------n----y-----�- ------------------------ .--.- -----------------Phone----- -- ----------- ----------------- <br /> Address. �� J��i ! / / -------- .. ✓ City _Te LV_----- -ZiQp------------------------------ <br /> Contractor's Name---- i GLa!=LC-------------------------------------------- License #�-%- 6 Phone_FFC5 ---!� -__67-- <br /> Installation will serve: Residence E] Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------- - - --------- ------ <br /> // r ,4 <br /> Number of living units:----1------ --Number of bedrooms_-4/---.Garbage Grinder_.._---__-__Lot Size------ ra�_____________ ___________C <br /> _________________ <br /> Water Supply: Public System and name------ -------------------------------------------------------------- ------------------------------ -----------------------------Private � <br /> Character of soil to a depth of 3 feet: . Sand ❑ Silt ❑ Clay ❑ 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 tpnk or seepage pit permitted if public sewer is available within 200 feet,) >� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-__�_X-ld1�__X_- ---------_--_--Liquid Depth__________ ________--=.5�1 <br /> / /� ,�,� <br /> Capacity/td� ----.Type-Poo( _`;S?,5$�Mate-rial--------------------------No. Compartments_ ----------------------Q <br /> Distance to nearest: Well --- --------------Foundation__/U.-j.7-------- Prop. Line_._____ <br /> LEACHING LINE [ ] No. of4ines.'_ ---�------------- Length of—each-line__ J__-__--Total Length ---3�---------------------- <br /> -t t-,� , ��I ' � 1J <br /> Q' Box_- _._Type Filter Material--4WADepth Filter Material-.----.- <br /> Distance to nares#:Weli__ -td' _____________ Foundation_. -!Z---------------Property Line_ C)----.--------___-.---. <br /> SEEPAGE PIT [ ] Depth_._-_:.._--__Did�eter.." Number._:.--.---_- -------- Rock Filled Yes ❑ No <br /> :-.. *— <br /> WaterTable Depth_------------------------- -----------------------------Rock Size --------- ------------------------ <br /> Distance to nearest:Well.-----------------------------------------Foundation----------------.-------- Prop. Line--------------------------- <br /> 7 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date--------------------------------- ---) <br /> Septic Tanis (Specify Requiremeni6' ---------- -------------------------- ------------------------- -------------------- ----------------------------------- --- <br /> Disposal Field (Splecify Re uirements)___ -_` c <br /> ------------------=--------------------------------------------------------=---------------------------------------------------------------------------------------------------------------------------------- <br /> F-­(Drdw eixisting'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 sub'ect eYAyk man's Compensation laws of California." <br /> Signed-- - - ------ - ---------------------------------------------Owner <br /> $Y------- --------------------------------------------------------------------------------- - --- -Title-------- ------------------------------- --------------------------------- <br /> (If other than owner) ' <br /> R DE TMENT gSE ONLY <br /> APPLICATION ACCEPTED BY_-_ ;° --.--__-DATE.-. <br /> - ------- <br /> DIVISION OF LAND'NLJMBER------------- <br /> -� -------------------------------------------------- -------------------------------- DAT --------------- - --- ----------------------- <br /> ADDITIONALCOMMENTS------------------- -------- ----------=------------------------------- - -----------.-_,---------------------------------- -------------------- <br /> --------------------------------------------- ---------------- --------------- ----------- - <br /> ----4------------- ----------------------------- -------------------------------------------------------- <br /> --------------------------- ----------------- - -- ----------- ---- ----- <br /> Final Inspection by------------------------ -----Date.-- <br /> ----------- <br /> EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />