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k <br /> FOR OFFICE USE: <br /> OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No----- <br /> ~� (Complete in Triplicate) L <br /> ` Date issued._OIj-r" -- --- y <br /> This Permit Expires 1 Year From Date Issued <br /> -------------- -- ---- --------- -------- --------. • <br /> permit to construct and insta <br /> Application is hereby mall the work herein described. <br /> de to the San Joaquin alOrdinaDistrict <br /> No. 549 and existing Rules and Regulations: a <br /> This'application is made in compliance with County Ordinance _ --�--- <br /> +,^ --- -----------.CENSUS TRACT------:------ ------ ------- <br /> JOB ADDRESS/LOCA <br /> ---------. ---------- -. ----------- <br /> ell <br /> f ( � ` - Phone <br /> - <br /> Owner's Name-------- -------------------- City Zip_ ------ ------------------ <br /> --- <br /> - -- ------ ---- <br /> --- - �.-"�`- ,_. <br /> ressAd`d <br /> one------ <br /> ��license # <br /> Contractor's Name-_:----- ----1 r` Trailer Court ❑ <br /> Installation will serve: s Residence ❑ Apartment House. Commercial ❑ <br /> a <br /> Motel Other-_ - <br /> Number of loving uriits----------------"Numb c.of,bedroo+rs_--- TG rbpge Grinder.-_---------Lot Size_----•`.-------_-- = Private:. <br /> _.---~— �--�.- <br /> ----------- <br /> -pP Y <br /> -System-and-name : -----=--------------- <br /> -- --------- -- <br /> Water-Su I Public ; z `{ .r. -- �-� _�; J , Sand Loarri ❑ Clay Loam ❑ <br /> Characfier of soil to a depth of 316L ` Sand ❑ Silt❑ Clay Peat❑� Y <br /> --------------------- <br /> - <br /> _'+--------------- i <br /> Hardpan ❑ Adobe ❑ Fill MateriaL_..----.----If yls, type, <br /> j bui]dings, etc. must be placed on reverse side.) <br /> (Plot'plan, showing size of lot, location of system in vela+°Herm+tedsif publit sewer is available within`200 feet,); I <br /> NEW: INSTALLATION: {No SEPTIC TANK <br /> [ ]e age p -p <br /> p P <br /> - Size----- -�--- -- --- �--- -------Liquicl�r Dept��;---------------------`-- t•� <br /> PACKAGE TREATMENT ['] Jf <br /> r.. <br /> ! Capacity - Type ;f= :Material ` No�Gampartments_ U <br /> I Foundation-i---- ----�-- Fro�?.mine <br /> �s Distance to nearest: Well.,-------.- -'_------- i `C <br /> v.. 1 . - �1 <br /> . t --r-. ----- ---_-- ----..Total Length---- ------ ------- ----- ------ <br /> YP b_lins.-_-- - <br /> L-EACHING LINE.. [ ] No. of Lines.---"" .---------- --- -- Length of eax , <br /> g erial_- ----- ------ --------------------------- <br /> Box------------T a Filter Material-------------- ------ <br /> ---Foundation <br /> -------- <br /> Depth Filter at <br /> p <br /> Foundotion_____-."_--------- <br /> ' - Property Line- --------------------- - <br /> Distance to nearest: Well- -- ------------------- <br /> Rock <br /> -- --- -------- Rock Filled Yes ❑ No ❑ <br /> SEEPAGE PIT f l Depth---------- ----Diameter- ---------- ------Number-----------.-----.--------------- <br /> �--- Rock Size---- -------------- ----------------:----- <br /> - Water Table Depth------'-'------------------------------------------------ ---- <br /> - <br /> ------------- <br /> Distance to nearest: Well_-.--_-_---__ -__ <br /> Foundation---- ---------------------Prop, Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit = <br /> ------ Date---- -- -------------------------- ----------- <br /> ! ----- --------------- <br /> Septic Tank (specify Requirements)__________ - <br /> Qisposal Field (Specify Requirements)-----.--. � <br /> l�a - --- ----- ---- - - -----` ---- ------. ..---- <br /> ------------------------ <br /> -------------- ----------- ---- <br /> - <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: ll not employ any person in such manner as <br /> "I certify that in the performance of the work for which this permit is issued, I sha <br /> to become subject to Workman's Compensation laws of California." _ I <br /> Owner 'av <br /> Signed------------------ --------- <br /> __J <br /> i <br /> ------- ----- 7� fC <br /> Title- <br /> -- ---------------------------- <br /> ------- <br /> -- - - <br /> (If other than ow <br /> DEP MENT USE ONLY' <br /> ----------- DATE.--- -------- ----- - <br /> APPLICATION ACCEPTED B .--___. DATE..__DIVISION OF LAND NUMBER ------------------- <br /> ---- <br /> ADDITIONAL COMMENT ----------------------- <br /> ------- ------ <br /> ------------- <br /> I ---------------------------------------------------------------------------- ----------------------- --------- <br /> -------------------- ------------- ---- ------- : �__�_h_9 <br /> ------- --- <br /> ------------------------------------------------------------------ <br /> ----- ----- ---- <br /> Da#e--- <br /> Final Inspection.p y---= -----------�- - � F&5 25677 REV. 7/76 3h <br /> EH 13 24 SAN JO N LOCAL HEALTH DISTRICT <br />