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FOR OFFICE USE: ✓�� FOR OFFICE <br /> APPLICATION FOR SANITATION PERMIT USE: <br /> (Complete in Triplicate) Permit No._,;� -:411qar <br /> i <br /> -- ------ This Permit Expires 1 Year From Date Issued Date Issued--„2��'�� <br /> w <br /> Application is hereby made to the San Joaquin Local Health District fora 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/LOCATI ON.._�,j�... .. v.---- -1Gfr- - <br /> CENSUS TRACT...------ ........... <br /> Owner's Name._........ <br /> . ... <br /> -- ------ ---- -------- ............ <br /> - <br /> Phone.__ <br /> - - ----- <br /> ..... <br /> Address..... ------ Cit <br /> .... _'&... Zi ............... -• <br /> Contractor's Name.___..._.. G_ - --------- ----License #-3©..D1...1./. .Phone.. ._ 9. <br /> .,3 Q <br /> 0 ... <br /> Installation will serve: Residence Apartment House ❑ Commercial [❑ Trailer Court ❑ <br /> M tel <br /> ❑ Other—..........--- .............. •-------... <br /> Number of living units:- ....! --Number of bedrooms.. .. <br /> J�] -...Garbage Grinder------------Lot Size... <br /> Water Supply. Public System and name. ........... . ---Private E-1• <br /> Character of soil to a depth of 3 feet: Sand E]. Silt [] Clay ❑ Peat ❑ Sandy Loam [] Clay Loam [ <br /> Hardpan ❑ Adobe ❑ Fill Material.. ___. . kf yes, type- 1 <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 I 1 SEPTIC TANK <br /> SizeXI � Liquid Deptt1 ... <br /> ............ <br /> Capacity Type_._ eial......MatNo. Compartments..... . .. .� <br /> Distance to nearest: Well............................ .... ... ....Foundation--------_ ... .... ....Prop. Line-.-. -.- --- <br /> ­­­.iA <br /> LEACHING LINE [ ] No. of'Lines -... .._...:- _ Length•-of each line.......�'.6------------ !T9tal Length .. <br /> D' Box...... ._-Type Filter Material._.... _Depth Filter Material.. ----- <br /> ax/fj.J? ,Once to nearest: Well------------------ ---------Foundation.------------------.-------------Property Line...------------------------....... <br /> SEEPAGE PIT "� .j•]£ Depth----__-- --...Diameter................----Number._...-------�,------------ Rock Filled Yes No <br /> Water Table Depth-------------••--------- Rock Size:--../ . --• .--•-- <br /> Distance to nearest: Well.-.---------- ------------ -------Foundation...........-.... -- Prop. Line..........-............... ' <br /> REPAIR/ADDITION (Prev. Sanitation Permit#............ <br /> ....-------.......----- ---------------Da#e....--------- <br /> ----._._...._........... <br /> Septic Tank (Specify Requirements) ---------------- -- - ------ = _......... <br /> ........--- <br /> Disposal Field (Specify Requirements)............•-......... <br /> ... ............... ........... <br /> „ <br /> ------ -------------- ----------------------------------------------- <br /> ...- ------------------------------ -- ------------ <br /> JDraw 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 Following: <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 /> T <br /> By.. .. Title----- -- -------------------------- -------- - -----.. ------ -- --... <br /> r( f tither JA <br /> than owner) <br /> ner] <br /> OR DE ARTMENT 4SE ONLY <br /> APPLICATION ACCEPTED BY---------.. . J CJ DATE . 77­ <br /> DIVISION OF LAND NUMBER.............. -----------------------------­ -­ ----------- - ------ --------------------------- .DATE. ...... -..... <br /> --- --- --- -- <br /> ADDITIONAL COMMENTS ......... -......_ <br /> ---------------------------- ..................... .... -- ---- -- ......... ....................... -- ...------......------ ........... ...--- -----.--------- ---- --- ....... ...... <br /> Final Inspection by:_..... .. f .............Date._..._p� .Zvv7 ........---- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f35 2F677 REV. 7/76 3M <br />