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FOR OFFICE USE: '"" FOR OFFICE <br /> APPLICATION FOR SANITATION PERMIT USE; <br /> - -------------- <br /> (Complete in Triplicate) Permit No_____ _________________ <br /> ------------------------------- ------- <br /> ----------- ----- j This Permit Expires 1 Year,F on Date Issued Date Issued._��� ._ <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. <br /> This applicatio de in p 'once with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADORES / OC TION :.WAW '_ --LL}�9'R-_0-1— � S <br /> t � p s u,�-_--- ----�"`'dQ,Q•?CENSUS TRACT----------- -------- <br /> ----- - <br /> Owner's Name - 1- ,°"" ; - <br /> = one <br /> Address. -� <br /> j- -- <br /> �- <br /> ._ .. . . -- --- -- -- �--- -�_ --.- �-:- 1tY �- - -- - ---- --- ��-- Zip_"_---: e <br /> Contractor's Name. - ;7 <br /> N License #- 6--.-Phone <br /> Installation,will serve: en <br /> 'F Residce [e Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> } Motel ❑ Other_______ ' <br /> - <br /> Number of living units:-------- ------- of.bedrooms_-_�--__Gorb__dge Grllld 1111 <br /> r___ __- _LOt Size______ -_------ <br /> __ <br /> Water Supply: Public System- nd name---------------- - - ------- -- --- <br /> Character of soil to a depth of 3 feet: Sand Silt Clay: <br /> i ❑ y;❑ Peat❑ Sandy Loam ❑ -Clay Loam ° <br /> 'Hardpan Adobe <br /> { If Yes, tYPe--�------- --------may--- <br /> ❑ ❑ Fill Material: <br /> (Plot plan, showing size of lot, location of system in relation to wells, 6ui1[dings, etc. m su t'be_Pelaced ori:�everse side.) <br />—NEW,,INSTALLATION: t4.(N6..septic tank or'seepage pit permitted if public sewer is available w.ithinr200 feet,) I <br /> PACKAGE TREATMENT.,( I. -SEPTIC 'TANK <br /> Size = ---- ----- -- Liquid Depth-=-------- -------------- <br /> - <br /> -. lea Capacity Type- •- �' 't AMate�rial ice_ r_No.C partments- --- --- <br /> ! Distance to nearest: Well <br /> :.., .--.---.Foundation .........-------------=--------------.'Prop. Line--------------- <br /> 0 <br /> ---=- ---- <br /> 1 <br /> ---- <br /> LEACHENG UNE [ ] No. of Lines-----------------------------Length of each line.-----------------------------Total. Length.._=-_---------_-,_ <br /> 'D' Box----------- Filter Material____________________Depth Filter Material__-___.__________ -------------------------------------------- <br /> Distance, <br /> ___- <br /> r ; . . I :• . - _ ----- -------------------- ---- -- <br /> Distance,to nearest: Well_------- Foundation_________-------------------- <br /> r' ,.-• Property Line-­----------------------------- <br /> D <br /> - <br /> SEEPAGE PIT r i A- - --------Number---:-____-- Rock Filled Yes ❑ No ❑ <br /> ] Depth.._ :__ _. Diameter__.___ <br /> Water Table-Depth---------- ---------------- Rock Size. <br /> Distance.to nearest: Well - <br /> -------------------------- <br /> I <br /> --- - Line <br /> I - -----=------Foundation-------- -.Prop, Line _ <br /> REPAIR/ADDITION (Prev!�Sanitation Permit#------------------------ ------------------ - .---- -- <br /> 1 I <br /> Sepftic Tank (Specify.Requirements)_--: t .� � ----------- <br /> ------------- <br /> ------------------------- <br /> ---------- <br /> I <br /> 01------------- --------------- ----------- <br /> - <br /> --- - <br /> --- <br /> z __ -Disposal Fisld(Specify Requirements) " - Q- ----------- <br /> ���2� - ---------- <br /> rT -------- <br /> -------- - ---- <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 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 /> "l terlify'that in the performance of'th4 work for which this permit is issued, 'I shall not employ any person in such manner as m� <br /> to become •subject to Workman's Compensation' laws of. California.. t <br /> Signed - --------- - Owner <br /> By- <br /> ------------------------------------------------------- ;Title_ " <br /> (if other than-owner) <br /> ¢ s FOR DEPARTMENT USE ONLY, " <br /> hzz z! <br /> } <br /> APPLICATION ACCEPTED BY_ -------------------------- DATE ... r <br /> DIVISION OF LAND NUMBER------------------------------: ---- <br /> - ----------- -- --------- DATE <br /> ADDITIONAL COMMENTS--------------------------- t - , <br /> . -------- ---------------- - <br /> ------------- ----- <br /> L <br /> _________-------------_---------------------------_----------_-------------__,_____ <br /> _______________"-___-______._______-___-_____-__ ------ <br /> --------------------------. <br /> Final Inspection by:_.:--�._-- '---:-- ---- <br /> -Date --- <br /> { <br /> 7 EH 13 24 SAN JOAQUIN LOCAL HE LTH DISTRICT F&S 21677 REV. 7/76 3M <br />