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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .. ................................ <br /> (Complete in Triplicate) Permit <br /> Date Issued./.l-,7 7 <br /> ................................. ....-----...._. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health Distr'ictdfor 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 /> �_amu - . <br /> JOB ADDRESS/LOCATION.__.....-. ` �[�fCi. t.-----i�`��`.- .-------.CENSUS TRACT..-----•-•-------------�....� <br /> � y.. <br />' L .hU- srT ............................ . --------- -...Phone : : ...----....._- _... <br /> Owner's Name._...... .... .0-�-- ---._V.'..... Pz.---�-�-•---- . ., . - - -.- .. <br /> Address-------------------- a.1... �.:../ r.r}� r'iJ� - ._..-----Cit `1� ca---------- Zi ��G' <br /> �y" <br /> Y---- ---- --...- P -----. <br /> Contractor's Name....... -6y d n t ..... i ...License # ---••--- ...................Phone------. ----- <br /> Installation will serve: / Residence Y 'Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_........------------------------------------ f <br /> r� <br /> Number of living units:......... ..._- <br /> -�Number of bedrooms._ .-T.Garbage Grinder---------...Lot Size---- ................ <br /> Water SuPPIY 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.) 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted it public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK t Size.................. 40A .......Depth,_._y.�._....--._..:__ <br /> CapacitY--/-2.Q¢.....:---TYPe <br /> �. 3 ...-Material-Grttn.C.l^ `-----No. Compartments...... ........... . <br /> ------------ <br /> Distance to nearest: Well--.__..7.S..a---t....................Foundation----_1..6 . ......... .. Prop. Line_..2S... '....-- ---. <br /> LEACHING LINE [ ] No, of Lines. ..........2......v--------Length.of each line..-------Es------------- Total Length /-Z4......._....__........ <br /> 'D' Box.... ...Type Filter Material,9�1,h!!4_L'.?4Depth Filter Material- ---------------_---- ----------------------- <br /> Distance to nearest: Well.^..�./l0_. -- Foundation.._..?L------- - ._..Property Line...., Q___f.......__..- --.-. <br /> SEEPAGE PITth. -Di <br /> p t rr <br /> [ ] De .a.a--. -- ameter_..--�.�-1,----- <br /> ...Number__-------_�--------•------- Rock Filled Yes R No ❑ <br /> Water Table Depth--------------------Ala_f--- ----------------­---- Size-.,-- ---------------- ---------- <br /> i <br /> Distance to nearest; Well...........:.. _' ........ ...__.Foundation................... Prop. Line.._..._.--.-.......------ <br /> .. <br /> REPAIR/ADDITION jPre'v. Sanitation Permit s#-------------------------------- ------Date-- ,-- '-----'-----------------------------I <br /> Septic Tank {Specify Requirements)------ ------- ------- -------- <br /> Disposal Field (Specify Requirements)._._............... . --- ............. <br /> Draw existing and required addition on reverse side) <br /> I hereby certify that l 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: r <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 je t to Workman's Co pensation -laws of California." <br /> i <br /> Signed....... . ----------------- Dwner <br /> BY-------- ----------- -'- <br /> - ----------------------------------------------- .......Title - ---.--- - ------- - --------------- -.--......-.......... .... <br /> -- <br /> (If other than owner) <br /> P47R DEPA M T USE ONLY <br /> APPLICATION ACCEPTED BY-•- . ...... --------•--- ......"..-----..DATE ---------7�... ...7 ...�� ------- <br /> DIVISION OF LAND NUMBER -.......��rcc/ ! l = 7r -__ .1 DATE <br /> ADDITIONAL COMMENTS---------- ---------- - . - ---•-------- ---------------- <br /> ----------------------------------------- <br /> ------------..---------------- ------._...------------ -- - ---- .............. ............... ------------------------- ............. .....-...--- ...... <br /> ----------------------------- kJOAQUIN <br /> -------------------- --•-----•------- -- - -_------- -- ----------- _ -- ---- <br /> Final Inspection by-------------------------_- -- - ------ - - ------ -- - - ..---Date. Li!� - . . ..eH 13 24 SAN LOCAL HEALTH DISTRICT FSS 216 REV. 7/76 3M <br />