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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ------------------------------r---------- , �. <br /> (Complete in,Triplicate) Permit No.__7�-43?_ <br /> -- ------ This Permit Expires 3 Year From Date Issued Date Issued---------_--------- <br /> _ <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/LOCATIO. .---_. _3'70_2 <br /> -. �� <br /> ---------------- - ----------- <br /> -------' _'___:,__.CENSUS i <br /> _.CENSUS .TRACT-------...-.... <br /> ---•_--'- .�.- <br /> Owner's Name._-_ <br /> r - ' <br /> : .,:��J -- --- --- <br /> Address. <br /> r -•- :, one <br /> _......g .., -------------------- <br /> : <br /> Ci ty � Zip p <br /> Contractor's Name------- - ---- , <br /> �:_License 7_3_ <br /> w '- Phone-:-.------------------------- <br /> Installation will serve: Residence <br /> Motel + :. +, Court ❑ <br /> . Ap❑artment House ommerci I Trailer + <br /> Other--- <br /> Number.of living units:------------------IVumber..of bedrooms ______P-__-Garbage Grinder__.:__..___ 0 Size_..-.., __.__ __.__._k ----` _ _ ___ ______ <br /> Water Supply: Public System and name __. ------- <br /> -----------------------------------------.__: <br /> ----M-7_------- ------------ <br /> ----------------------- <br /> ------ Private <br /> Character of soil to a depth of 3 feet: Sand 'Silt❑ ;Clay El Peat L] Sandy Loam Clay Loam ❑ e <br /> :. .. <br /> Hard an <br /> p ❑ Adobe;❑ Fill Materia!-_..--- ---If yes, type------------------------ ------ $ �..- <br /> (Plot plan, showing size of lot, location of system in reiation to wells, buildings,.etc. must-be,placed on reverse side.) <br /> NEW INSTALLATION:` - `(No'septic to or seepage :pit permitted if public sewer is available with-iri 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' ' <br /> -------------------'------------ -- <br /> .. Capacity '= ='=I ]YP Size-Ma Liquid Depth. -- - -------- <br /> _ -Q <br /> �T e ":__-_= tariaL -_ <br /> --------------:_No: Compartments-----_---- , <br /> 1 ; Distance to nearest: We!!.- :,----- ound n <br /> LEACHING LINE s e _-___-:-- 4 <br /> -----F atio -- i_- -------Prop. Line_-_ ---------------- <br /> ].. No. of Li.nes = -----..Length of each line,__----- - Total..Length. <br /> - <br /> e <br /> # ; D' Box--€-------- Filter Material---------------------Depth Filter Mater ial <br /> --------------- '- - <br /> ' .� .. ,.... .�.. .F ---- ---,y----------------- -•�, --------- <br /> 'Distance'to nearest: Weli_' ------------------Foundation---=------�-.---------------Property Line---..------------ <br /> SEEPAGE PIT [ ] Depth-_.-'----- Diameter--------------- Number---_-----. ------------- --__-- Rock Filled Yes ❑ No❑ <br /> Water Table Depth--------------- ------=---- ----------- - ---- -----Rock Size-.-----'-- -- <br /> Distance <br /> f, <br /> to nearest:Well. <br /> -----Foundation Prop. Line---------- ------------- <br /> REPAIR/ADDITION (Prev:Sanitation-Permit#-..--_-__------------------------ <br /> Date------------'_ <br /> Septic Tank (Specify Requirements)_ :__:-----------____________ <br /> --- -----e---'- -----------'------------------------`----__ <br /> . ---------------------`---------- <br /> j <br /> Disposal Field(Specif Requirements).-.--�-� _ <br /> -------------------------- ------ <br /> ------------- -- = -- <br /> - ig---- <br /> ._ .. ..... ... ...... _ _-------------------- ----------:- - - ------------------------__.. T J <br /> ---------------- "- _. <br /> I hereby certify that I have prepared this application and that the 'work will•he•done in accordance <br /> ------------- ---- ---------- - <br /> _ {Draw existing and required addition on reverse side) <br /> Y Y p p with San Joaquin County --„ <br /> JA <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: I �. r' <br /> "1 certify that in the performance af°the work for which this permit-is issued, I-shall'not em to an'�`—�""' - � <br /> to become subject to.-Workman's Compensation .laws of California P Y Y person m such manner as <br /> Signed--r,------------------------------------= <br /> BY------- ------- ------ -' Title-- <br /> - - ----------- ----------------------------- <br /> (If other than owner) i <br /> f' 'F R D TMENT USE-ONLY - <br /> APPLICATION ACCEPTED BY__.---- ---- = ; <br /> ' - --------- --- ---------------------- DATE <br /> DIVIS <br /> ION OF LAND NUMBER. DATE- ---------- <br /> - <br /> lTIQNAL COMMENTS------------- -------- --------- I <br /> ------------------------------------ ------ ------- <br /> I -------------------------------------------------------------------------------------------- <br /> 11 <br /> ---------------------------- - --------- <br /> Final Inspection by: ----- .._ - ----------Date----.. f <br /> EH as za # N JOAQUIN LOCAL HEALTH DISTRICT <br /> _ F&S 21677 REV. 7/76 3m <br />