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FOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.__.7�_`.�.7___ <br /> -------------------------------- ----- ---- ------- <br /> Date Issued._1�-1;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 with County Ordinan No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.__._:___/__� -_ ._ ____________ ______CENSUS TRACT._-------- _._.. <br /> - _ <br /> Owner's Name..--� --------- -- - --- ------- ----------- ------ --- ---Phone —- ----------------------- <br /> '71? <br /> J -- <br /> Address <br /> -.. ��� City Zip-------------------------- -- - <br /> Contractor's Name. `' Q G --------------------------- ------.License #_ �L__r -3_/-.PhoneLlIa ; <br /> �-r- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------------=------------ <br /> Number of living units:._ _______Number of,bedrooms-30 garbage Grinder------------Lot Size_. -------------------- <br /> Water <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 ❑ a <br /> Hardpan ❑ Adobe ' Fill Material._-______..Jf yes, type_ti_______________._______.___._ <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 tank or seepage pit permitted if public sewer is'available within 200 feet,] <br /> PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size-------------- .___.__,:_____Liquid Depth______._..___.__._______ <br /> .4 ; J <br /> y� <br /> Capacity---------------------Type.-----------------=---.Material--------------------------No. Compartments-----------------•----------------;D <br /> FI, Distance to nearest: Well-----------"-----------------------------`F,oQhdation.----'3-----------------------Prop, "Line--------------------.- <br /> LEACHING LINE [ .) No. of Lines-----------------------------Length of each line______ ~;'._._____.___.______.Total Length - <br /> i <br /> t f D' Box---------°--Type Filter Material------- ----------- Depth Filter Material-------------------- <br /> i Distance to nearest: Well----------------------------Foundation----------------------------Property Line--------------- -------------- <br /> SEEPAGE PIT [ ] Depth------------- __Diameter---------------------Number--------------------------------- Rock Filled Yes.❑ No <br /> WaterTable Depth----------------------------------------------------------Rock Size---------------- ------------------------------- <br /> Distance to nearest: Well------------------------------ ------------Foundation---------.--------- Prop. Line--------------------------_ , <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------------------------Date--- ------------------------------------------ <br /> Septic Tank (Specify <br /> _ -----Requirements)____. <br /> ___- _ ______________ <br /> e � (Disposal Field (Specify Ruirements1. _ _________ _ ____ <br /> ________• <br /> =--- ------ ----------- --------------------------------------------------- ------------ ------------------ -- -------------------------------------------------- <br /> = ------------------------------------------------------ -- -- <br /> (Draw existing and required addition on reverse side) {r <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Couhity, <br /> Ordinances, State Laws.- and Rules and Regulations of the San Joaquin Local Health District. Horne owner or licensed agents <br /> signature certifies}tire following: . -�� �„ r frrf` <br /> "I certify that in the performance of the work for vvhich'this'permit is issued, 1 shall not employ any person in such manner as <br /> to become sub) t to or a 's ion laws of California." <br /> Signed =----- ----, e� ---------------Ownar <br /> BY ------ - Title /.. <br /> � t <br /> i (If other than ow�ner�'� ��� <br /> rlp�,,., ,. »� r FO EPARTMENT'USE ONLY r. <br /> j t74 <br /> F F <br /> CATION ACCEPTED-,BY — 'Y -' --------------DATE f ------ ..------- - <br /> A LHON OF LAND NUMBER. .,. , -=------ -DATE.-- =;- <br /> ADDITIONAL COMMENTS = = _ -------------- <br /> 1 .f" 1 -° - ­­----------------------------- ----------------=-------- <br /> � y <br /> f <br /> -------------- --------- ------------------------------------------ `----------------------- -- -------- <br /> ------- ------------- - - - --- <br /> Final Inspection by:-- ----, ---- ------ -----: ------------------ ----- ---Date.---- --------------=------ <br /> EH 13 24 SAN-JOAQLIIN LOCAL HEALTH,DISTRICT' F&5 21677 REV. 7/76�M <br />