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iFOR OFFICE USE: FOR OFFICE USE: <br /> .� APPLICATION FOR SANITATION PERMIT <br /> ------------------- ---------- ----------- <br /> -- <br /> � {Complete in Triplicate] Permit <br /> ------------------------------- ------------------------ <br /> Qgte Issued_/D._/.,A__-�� - <br /> •••,------.---------------------- _______________ This Permit Expires 1 Year From Date Issued I <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 .-------- --- .CENSUS TRACT.------------------------- I-- <br /> J <br /> Owner's Name- ----.-��' -------- LCX ---- ---�-� .� Phone _ 4 { <br /> f� <br /> Address-----=--- ---- ----/_67 U----;`'""''r��lt'Q_------------------------------ city--- ---- --_ - -----------------Zip----- ------------------------ <br /> Contractor s Name c_.. = -License #A4�q_.?r__'�'3-----Phone__..- <br /> _ _ t <br /> Installation will serve: Residence k, Apartment House.❑ Commercial ❑ Trailer Court ❑ k <br /> _. .. i' i Motel-❑ --f Other `'---=='=---`--- <br /> ----------- <br /> Numberof,living units:------- _------Number of bedrooms_ _`_ =:___Garbage Grinder.---_------�.jot-Size � <br /> . -------- <br /> __. <br /> 4 <br /> Water Supply: Public System and name------- ----_--------_-_--_--` ------i----------- ---._-_:..__.------.-,.._------------------------------:--_----- . -----------------------------------=--:Private � <br /> Character of soil to a depth of 3 feet: <br /> ] Sand Silt Clay Peat Sand Loam Clay Loam [ <br /> _ ❑ ❑ Y ❑ : ❑ Y Y <br /> �._____ <br /> ,Hard an Adobe i <br /> p ❑ ❑ -,-Fill Material ^`If yes;^#YPe�' -.:..,. - � <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.'must be:plac'd on reverse side.) <br /> NEW INSTALLATION: iNo'-septic tank :or seepage pit permuted if public i6weris a aiiable within 200 feet,] <br /> " <br /> i <br /> Depth pt ____________-------- <br /> ---------------------------- <br /> -- -- ---TANK' 4 "Size TREATMENT SEPTIC Liquid' Material ' NCompartments <br /> --------- <br /> Capacity,----- T � ype--- --=------._ : <br /> V <br /> i Distance to.neW <br /> • Wou-n:d.;a._#� ` � Pro--p--.- Line---------------------� ------------------------;--,---LEACHING LINE., [�] No. of Linesfl� -----.------.Length ofeachI.ine.__-,_. _ -_ -_-.-.TotalLength. <br /> ---- <br /> D' Box_. -_Type Filter Material (`t Depth Filter Material <br /> l Distance'to nearest: Well- ~=_t_t_:Ri>_ `Foundation___ .___._'______�__.._;.-_Property Line__._ ____- <br /> SEEPAGE PIT ;[ ] Depth--------- -----Diameter- --_--.i____._____Number__ _-_._____---_- -____-- { Rock Filled Yes:❑ No ❑ <br /> I {' <br /> Water Table;Depth---------- ------ ------------- ---------�` Rock Si e:,af = - ''-x s: <br /> 'Foundation Pro Line. <br /> pistance;to nearest; Wel -..____._.____._ - p. <br /> I <br /> REPAiR/ADDITION (P :Sanitation Permit#--------------- ------------------------------_.Da-------�- � --- - t <br /> ] •� J <br /> Septic Tonk (Specify Requirements).--- -- _:____:_- =I ------ <br /> -:--- <br /> fJ; /�K n _ s ' <br /> Disposal Field (Sp edfY Requirements} _----------- ----------- -- ----Z�-----�� "------------------------------------------ <br /> -------------- <br /> '-------"" <br /> --- - • --------, = $ <br /> - <br /> ---- --- - -- <br /> = Y ---- ------ i--------------- ------------ -- <br /> .��^ - - ;an Jo m <br /> � {Draw existing and•required addition:on reverse side) <br /> I herel y certify'that.1 have prepared"this application and that the :work will-be�done-in--accordance with-S` aqui —County <br /> Ordinances,: State Laws; and Rules and Regulations of:the' San Joaquin Local Hecslth District. Home owner or licensed agents <br /> slgnptur`e certifies the following <br /> "]Wc rtify that in the performance of the work for which this permit is issued, -I shalt'not employ any person in such manner ias_Al; <br /> `-td became subject to. Workman's Compensation:,laws of California." s <br /> I r <br /> Signed---- a <br /> ------ -- ------- -:. . ---- --:-. _--O_wne.r <br /> . _ <br /> ----------- <br /> Title .---- `---- --By- - ------------ <br /> (if <br /> l <br /> otl7-er­+6n':owner) <br /> +- FOR EPART ENT USE ONL <br /> SSC <br /> APPLICATION ACCEPTED•BY• - ------- -`-------------:---DATE.--------la �� ---- -- --i--- r <br /> DIVISION OF LAND NUMBER._��_ -- --- -----------------DATE.,------------ -------------- ----- - <br /> ADDITIONAL COMMENTS-----:--!d:4 - r ° <br /> t = = == -- - --------- ----------------------- ----- ----------------------------------- - --- =- - -- <br /> -=- <br /> I -- --- ------- --------- ---------- -- ----------------------------- <br /> ------- -- <br /> --------------------•------------------- - ---_ --- -------------- ----------------------- ------------------------ --- <br /> Final Inspection-by:- � - - - ------- - -------- - Qat <br /> _. .a <br /> �'�� e .�/ `�0_- t 1 <br /> EH 13 24 4;PLAN JOAQUiNt•LOCALrHEAL-TH DISTRICT F&s 21677 REV. 7/76 inn <br />