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F FOR OFFICE USE: FOR OFFICE USE: <br /> s <br /> APPLICATION FOR SANITATION PERMIT <br /> "n (Complete in Triplicate) Permit No.7�'�1�--- ; <br /> } <br /> Date Issued_1 1 .�_� <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�®--.. 11.. .. CENSUS TRACY-.-.. <br /> Owner's Name.... .. .......'L.I,J .�L1�a ....................... Phon-e:.. --=------ ----------...-. <br /> Address-.. :_ �-�---- ---- City....-.- ZiP <br /> i <br /> �L <br /> Contractor's Name... .......... :.. -.,r�azc .... ..-,...License PhoneV4`I7 0` _ =--•, <br /> lnstallation will serve: Residence. Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel'❑ Other <br /> .......... ...... <br /> 65 K4z 0 <br /> Number of living units:------ --------Number of bedrooms-.-. ... . Garbage Grinder---.----_--Lot Size.------. .. . - <br /> Water Supply: Public System and name . .......... . ... ..:.. Vi`.µ _-_"-------._._ -- -------------------------- .................... •------ ----Private ❑ i <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt1❑1 Clay E] Peat ❑ Sandy Loam ❑ Clay Loam E]Hardpan E] Ado6&e K" Fifl'Material - --- ....If yes, type-------------------- <br /> -----' .- . <br /> t <br /> {Plot pidn,,.showing size of lot,,,location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALIATiOfVa (No'septic.lank or seepage fit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT ( ] SE-PTIC TANK [ ] Size..--------- ----- --- :--"-: - `---'--Liquid Depth <br /> * y� # <br /> ; Depth.--- <br /> ------------ <br /> capacity.:,­P Y ..,.--...TYP,e •---- --- Material!.------------ --. _.•_..No. Compartments_---- _-------: <br /> ---- <br /> iDlstanceao nearest: Well-: Prop. Line.... <br /> -...........FoundatiLEACHING LINE [ ] No :of Lines -- ------------------------Length of each lino - Total Length ... -.-.---..- <br /> 11 <br /> "'D'.�Box:.Zl....-. .Type Filter Material...i..... ...........Depth Filter Material.. ----.......--_--...---........------- --------.....-.--. <br /> Distance to nearest:-Well...:.- ...........- Foundation------------------- ...-.,Property Line----- -_ - ----------_- <br /> SEEPAGE PIT [ ] Depths--. _..'..--_Diameter-----------------r Number-: .:. .-..-..------ .-:..- ... �, Rock Filled Yes ❑ No <br /> 4 <br /> Water Table -Depth-----------------------k - Size-- - <br /> • ro e <br /> Distance to nearest: Well.- <br /> --------- <br /> ell.----. - --. ---. ------Foundation.......... ............Prop. Line_ ....-: ------------ ---- <br /> REPAIR/ADDITION JRrev. Sanitation Permit#------------------ ---------Date........:.--------------- -----------:_) <br /> Septic Tank (Specify Requirementsl. $...... <br /> ----------------------- -------- ----- --------------------- <br /> Disposal <br /> ----Disposal Field (Specify Requirements)..- -... ....... -•--0215 � -_- - -- -------• l <br /> - ------------....... `f c...-- 1X f Q ..----- -- <br /> - l <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 fallowing: b <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 /> - <br /> ------ <br /> By.. --------: ..Title ... <br /> (If other than owner] I <br /> E91117EPART6II4T U5 PNLY <br /> APPLICATION ACCE ED BY- - 7 -- -------------------------- DATE -- 7_..-7 P..---......... <br /> DIVISION OF LAND NUMBER.-...........-- .- ' DATE----------Z-------- <br /> ADDITIONAL COMMENTS----------- .......- ._- ------ ----- - - ---- - <br /> ------------------------------ ---------- ...... ...- ... <br /> � � Y1 -- moi. <br /> ----------------------- ---------- ---- -----------=------------------- -------- ------- <br /> - _. <br /> -----------•----- ---------- ------------ ----------- - --- h_ 1} 7 <br /> Inspection b .. . .......... - ..--Date...-- �`- "�-. ----- ----- ----- <br /> Final <br /> y:.... - --- ------------ ------------ <br /> E" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />