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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----•---------------------------------------------- - (Complete in Triplicate) <br /> Permit No.-_7.�'--_7 <br /> - <br /> -- <br /> � s - Date Issued_ __J__—_._-__7 <br /> ! <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_----------- � o ?- -- l76 /P - -----CENSUS_-TRACT:__ ---------- <br /> _- M �. _ __ <br /> -Owner" Name_. _- � L?-/-------- ------- <br /> -------------------------------------------------- � Phone --------- <br /> - - <br /> Address <br /> ---- -------------- <br /> - --------------- ---- City 4 r r C3y ----------- -ZiP---------- .--•-------- <br /> ' 5 "?3 ----Phone tT51 ��!/6---- <br /> �Contraetor s Name�`z---�/�.r-- ,��-- - -- - -----•------------------------------;License #���---------- �----- <br /> L.Installation will same: Residence[ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> r <br /> Motel ❑ Other----------------------------------------------- <br /> [Numbe'r <br /> ----------------------------- ------------ -'Number of-living units:------ --------Number of bedrooms. --Garbage Grinder------------Lot Size--------- ------------------ ------------------- <br /> Water <br /> ________________VWater Supply: Public System and name------------------------------------------------------------------------------------------------------- --------- --------------i Private A . <br /> ,Character of soil to a depth of 3 feet: Sand' Silt Clay Peat Sand Loam Clay Loam V <br /> p ❑ ❑ Y ❑ ❑ Y ❑ Y ❑ J <br /> Hardpan M Adobe ❑ Fill Material__ If yes, type-------------------------------- <br /> I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> FNEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> �PACKAbE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------�. K_ —:---------------------Liquid Depth.---- 4 <br /> Capacity---------------------TYPe----------- ==_.___Material------- -------------?....No. Compartments--------- ------------=----------- <br /> Distance to nearest: Well-------------- {-----_---------------------Foundation--------------------------Prop. Line-------- -------------_.---- <br /> � gg a <br /> - D' Box------------T a Filter Materiaf�____.____:_�=.-___[fie th Filter MatF .Total Length --------------------------------------• <br /> LEACHING LINE [ ] No. of Lines-----------------------------Len th of each liras---------_________ <br /> ------------------ <br /> YP p ---Trial-------------------------------------- <br /> s i , <br /> 1 <br /> Distancato nearest: Well------_---- __ Foundation3-------- ------.Property Line---------------f------------------i <br /> 1 � <br /> SEEPAGE PIT [ I Depth ------------Diameter-------- ___;____Number _ :-------------- -_ Rock Filled Yet ❑ No❑ <br /> Water,Table aopth --- - ------- Rock Si e <br /> Dista e'.to nearest: Well. ----------s------------------ Fob ndatio -------------------------.Prop. Line--------=------------------- <br /> ----------------------------------- <br /> Septic. <br /> ----------------- <br /> ----------- --------------------Septic Tank 4Spec4 Requirements)------------------------ --------------- <br /> - - - _- ------- ,=- ;;---------- ------------ ------------- --- --------- <br /> Dispos"I Field! ecif Re uirementsQ - ---- -------------------- <br /> - <br /> i{SP . Y q _ _.) C �l G_ <br /> _ s ' <br /> ---------------------------------------------- <br /> - -------- - <br /> i 3 <br /> Y <br /> • 5.. -i : <br /> �D_raw <br /> ----------------- <br /> ------------------------------------------------------------ <br /> existing cirzd�equire�4l t�ddition o , reverse side) '7 <br /> f <br /> I hereby certify that'I have prepaf` cl­thisjapplication .dFiil�that4he ;w,0k will ,be :don in accordance with San Joaquin County <br /> Ordinances, State lL'aws; and Rules 5'i#nc� Regulations of the San Jo(qui6 L' cal Aealth District. Home owner or licensed agents-: <br /> signature certifies the Following: <br /> ` "1 certify that in the performance"o`f` lie work forT"i,Firc�}t•this-Oermit is JlssW I sh6ill not employ any person in such manner as <br /> to become subject. to W rkman's Compensation laws of California.';.. i <br /> Signed } � <br /> � �. <br /> T' e ---------------- <br /> ----------- ) ---- ------------------ <br /> (if <br /> E _ <br /> - ---- --- <br /> {If other than own <br /> 1 <br /> ;l i <br /> �.} ONLFOR EPARTMENC USE <br /> I i. <br /> i <br /> i <br /> 7 <br /> _ - -_. DATET APPLICATION ACCEPTED 'BY_�DIVISION OF LAND NUMB_ ----------------------- =--=-- ---------- -- -•---------------=•------------- DAT ------------------------------------------------ <br /> A <br /> ADDITIONAL COMMENTS----------- y- ------ =:e._r_ :; e : ___:-•--... �._:,-._.:.... T • - — -- <br /> -------------------------- <br /> l�l F11 I ----------- ------------------------------------------—-z--------------------------------- <br /> ----------------------------------------------------------------------------------------- <br /> -----•------------------------------------------------------------ <br /> ------------------------------- — /.:r <br /> . - <br /> F1 <br /> Final Inspection by: .� Date <br /> - .. - - ---- --- <br /> -i EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2i 677 REV. 7/76 3M <br />