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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMITFOR OFFICE USE: <br /> ------------------------------------------ <br /> --------------- <br /> (Complete in Triplicate) FOR <br /> No.7 '.3d� <br /> -------------------------- ---- <br /> This Permit Expires i Year From Date Issued 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 Regultioras; <br /> JOB ADDRESS/LOCATION.__ f C/o-7 <br /> ------- -- ------------- t2_ � fr <br /> -------.CENSUS TRACT---------- ---- <br /> Owner's Name----------- - <br /> ........ - -- ---- .: ---- -- --...--- -Phone ---- --- ------------- -- <br /> Address 7_. - City �• <br /> -- - -�n� � .�.. - - ------ �---- ---- Zip----------- ------------ <br /> Contractor's Name-_------__-- a - ---- - --- -- License # 3'82 -G--Phone------------- <br /> Installation will serve: kesidence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-------------- <br /> Number of living.units:...... <br /> l--------Number of bedrooms------ Grinder---._-___---Lot Size___________________ <br /> _ -----=----------------------- <br /> Water Supply: Public System and name________________ ____________:__Private IE ;t <br /> Character of soil.to a depth of 3 feet: Sand Silt Clay p ❑ ❑ y ❑ Peat❑ Saridy Loam ❑ Clay Loam ❑ <br /> Hardpan Adobe ❑J Fill Materia ------------ 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'per%6tted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK i r • ______ _________"_' _ __--_Liquid Depth____--__________._ <br /> [ ] 1 Size <br /> y Capacity,-_-- . i-------'Type-------------��Mater`ial---=--- = No.-Compartments` ---------------- --� <br /> Distonce:to nearest: Well------------„-----_ . �.~----------Foundation-----------w--------------Prop. Line--------------_________ <br /> LEACI LING LINE ,[+l No. of Lines--_____ _________-__-_'__=.Length of each line_________________ <br /> Tota! Length. . <br /> - ------------- <br /> T 'D' Box------------Type Filter Material-------------------..Depth Filter Materia_I--- ----------- <br /> 4 Foundation----------------------------- <br /> t Distance to nearest: Well = ----- Property Line------ ------------------------- <br /> SEEPAGE PIT [ ] Depth-----------------Diameter_:_------------ Number-------------------------------- Rock Fillet! Yes❑ No ` <br /> Water Table Dep#h. -------------------------------------------------- Rock Size--- ----- <br /> - - ------------------------ <br /> Distance to nearest: Well----------------------------------------- -Foundation-----------------------_..Prop, Line------------------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit# --------------------- <br /> Septic <br /> __-_____-_ <br /> Septic Tank (Specify Requirements)___________ _______:_._ ) I <br /> - -------------------- ------------------------------------------------1,Field (Specify Requirements)____ -------------, - -__*' �2' <br /> r --------------------- <br /> ------------------------- <br /> " <br /> -----'---------- ---------- ---'---------------------=_-------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> herebycertiif that 1 have <br /> -certify prepared this application and that the work will be done in accordance with San Joaquin County A <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 /> R <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ 1 <br /> p y an y person in such manner as <br /> to become subject to Workman's Compensation�laws o California." <br /> Signed ------------- --- --------------- ---- = Owner i t <br /> " - ------ <br /> gY---------- ---------- ----- ------R------1 [ --Title---- = <br /> (If other than owner) <br /> FOR-DEPARTMENT USE ONLY <br /> .APPLICATION ACCEPTED I3Y.___ - ___ ___ __ <br /> ------ --- �--- --------- -------------- ----------- DATE. --� -- -DIVISION OF LAND NUMBER ---- --------------- ---------DATE------------- <br /> ADDITIONAL COMMENTS ---- <br /> --------------------------------------- <br /> ----------------------------------------------------------- _---------------------- <br /> -------------- -------------- <br /> t <br /> --------------------------------------------------------------- ------------------------------------------------------------------------------------------- ------------------- -- --------------- <br /> --------------------------------------- - --- ------------- <br /> 7f _ <br /> ----------------------------------------------- ------------- <br /> Final Inspection b Date-___ _ <br /> p Y --------------- <br /> D <br /> - 2 _ <br /> 7 <br /> E!1 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />