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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit <br /> ......................... ...... ...------------ <br /> Date Issued..V-�114--_79 <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 anodsti�n <br /> � <br /> exRules and.. R.egulal.t.i.o..ns: <br /> ------- .JOB ADDRESS/LOC P ------- ---------.CENSUS 'TRACT <br /> ... <br /> --4.�y. <br /> .... ......... <br /> 'Phone------------- <br /> Owner's Name.... .--..-X ... PCity. � L' 0 " .......zip <br /> � G /- /.................Address..................... . .. ... <br /> Contractor's Name- - Q ... .... .............. ....Licensehone. . <br /> ,• Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------- -- ..... <br /> k <br /> Number of living units---- ------------Number of bedrooms......---...Garbage Grinder------------Lot Size............_._ .. ._ ..-....----------_........- a <br /> Water Supply: Public System and-namd__..__.­__ =-_---=�`T: = Private ❑ <br /> I Character of soil to a de Hardpan et. Adobe Silt Material❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br />� P ❑ ❑ Y _ <br /> P ❑ ❑ l.. .... ....If yes, type-•------------------------------- <br /> (Plot <br /> ----------- .--- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> i NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( j SEPTIC TANK [ j Size _ .-----.Liquid Depth----------------------- <br /> Capacity- --.Type------.--- - --Material------ ..........No. Compartments--............,......... <br /> T <br /> Distancb'to nearest.W611.` .'....................Foundation..____ -- - ------ -. Prop. Line....-............-....-..... <br /> J� <br /> fi <br /> LEACHING LINE { j No. of Lines A.......-------------------Length of each line------ --------Total Length .- ------------------------------------V <br /> 'D' Box............Type Filter Material_..............--..Depth Filter Material....................---------------------------------- ---------.5 <br /> Distance•to nearest. Well....`.....-_...............Foundation-----_-.-----------:......Property Line----------------------------------.. <br /> SEEPAGE PIT { j 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. So'nitation'Permit#-.-•-------------=---------------------------------Date----------••------------_------------------- <br /> Septic <br /> ---_---- --------------Septic Tank (Specify Requirements). .... ........... ---------------------- <br /> - ------ ------------------------ ------- <br /> Disposal Field [Specify Requirements[.............. '-• <br /> • ---------- <br /> ------ -- ---------- <br />! y (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 /> 1 Ordinances, State Laws, and—Rules ,land 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_ .- -- --- --- -------- - ------------ ......------------.-- .Owner <br /> By-..-...-•--- � r l� �. ------------ ------------------------- Title ��n <br /> (If other than owner) j <br /> fqg.DEPA MENT USE ONLY g <br /> APPLICATION ACCEPTED BY------- . .......... --- -- . ....... - -----------..DATE ...... ........... <br /># DIVISION OF LAND NUMBER-------------- <br /> -- DATE---_...--- ----.- - <br /> 3 ADDITIONAL COMMENTS.............. - <br /> ---------------------------- -------- I.... ---------------------------------- --....-------- <br /> f ---------------- ------------------- :: ..... --------•----------------° ------------------------------- ---- ------ <br /> ------Date.......... F& . <br /> Inspection b ��:.�.� �------------------------------- --------------------- - -------------- S-- `-- cl•---- -�- ----- <br /> Final, Y• # F8S 21677 REV. 7/70 3M <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />