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FOR OFFICE USE: FOR OFFICE USE- <br /> --- <br /> FOi SANITATION PERMIT <br /> ---- - -------- ---- -- --------- Permit No.---- - <br /> (Complete in Triplicate) 7� <br /> -------------------------------------------------------- <br /> Date Issued______ <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 �.f..-r 3 � {LC). � --------------- :.. = CENSUS TRACT <br /> Owner's Name --- ---',1-Sat-- �T��a��s'�-!-- ------- --------------------- ------ ---- --------- <br /> -_ - „ Phone----- <br /> ----------- ------ :------ <br /> GtU <br /> Address----------- -- ---- -- ---- - - -------------- ------- City ------------- ------Zip ��1 <br /> Contractor's Name L .... �'� --------- ------ _License #..3.z Phone <br /> Installation-will serve: Residence u Apartment House Commercial ❑ Trailer Court ❑ , <br /> Motel ❑ Other---------------------- <br /> Number of living units:------I---------Number of bedrooms:__3_----Garbag Prindar_:. ------- Lot Size--------------- ---- -------------------------------- 1 <br /> Water Supply: Public System and nam e-------------------=------------------------------------------------- ---- ------------.-.----------- --- ----------- ------------------Private ff, , <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted i#public sewer is available within 200 feet,! <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth----------------------:-V� <br /> Ca )cit Material------------------------ -No. Compartments------ .-----------------� <br /> P Y;--------- -------- -Type------------------- <br /> Distance to nearest: Well.------------------------- -------------Foundation--------------------------- Prop. Line--------------------------` <br /> LEACHING LINE- [ ] No. of L''ines----- - __.Length of each line-------------------------------Total Length-------------------------------------- <br /> 'D' <br /> .....----- -----------_--'D' Box----.-------Type Filter Material-:--.---..............bepth Filter Material-------I---------------------------------------------------- <br /> __ <br /> y � I <br /> Distanceto nearest: Well___.........- Foundation-._--—-------------------Property Line-------------------------- - v <br /> SEEPAGE PIT -[ ] Depth--------- ----Diameter---------.----------Number------------------------------------ Rock Filled Yes ❑ <br /> iWater Table Depth-------------- ---------=---------------------------------Rock Size------------------------------------------------ IN" <br /> Distance to nearest: Well-----------------------------------------------------------------------Foundation___..... ----- Prop, Line----------------------- <br /> ... <br /> REPAIR/ADDITION-(Prev. Sanitation Permit#....... .�-- - ................Date-- .------- 7 - --<-- - -------1 <br /> Septic Tank (Specify Requirements) -------------------------- ---- ---- --- - _ ------- -------- <br /> - - --------------------------------------------------------------------- ------------------------- <br /> Disposal Field,(Specify Requirements)_._.- ---- A -_& --- ------ ------ " <br /> ' ------------------------------ ---------- <br /> -----------•..................................................................i--------- /�'�.'�_ ------------ ... <br /> V <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 accordancewith San Joaquin,County <br /> Ordinances, State Laws, and .Rules and Regula:tionsfof the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: i <br /> .1 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#,4 <br /> t = <br /> BY{ i = Title---------- ---------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY ' <br /> i <br /> APPLICATION ACCEPTED BY'_ W- - ------------------- ------------------------------DATE.-- -- <br /> DIVISION OF LAND NUMBER.-- I?ATE. <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------- -------------------=----------- -------- --- ---------------------- ------ <br />' f --- ------------------------- <br /> ----------------------------------------------------------------------------------------- <br /> ---------------- <br /> i ---------------------------------------------------------------------- <br /> ...-_'------------------------------- --------------------------- --------------------------------------------------------------------- ------------------------------------------------------ - <br /> --------------------------------------------...... .. ___ .-. - - ...-..-.__...... <br /> Final Ins / <br /> -- - - -- -- --- - --- - ------ - - -- -- - ------- -- - ------�---- -� - <br /> -Inspection,by p Y:-.�... ---------- - -- ----- -Date. ------------- <br /> EH 13 24 / SAN JOAQ LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M <br />