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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> `- - -- -- -- (Complete in Triplicate) Permit No...�-`I-..�., . ..7 <br /> Date IssuedS-/3'?` _- <br /> •---•--•-------.---.-.... --._ _ --- ------ This Permit Expires 1 Year From Date Issued <br /> L , <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 /> ._.... . . - ..•. K - <br /> �CENSUS <br /> / <br /> TRACT-.......... <br /> - l-.-..----- .-.._.-..4WB ADDRESS/LOCATION......... 7 fP / <br /> f :' � ......Phone._._.-.-...-... ....................Owner's Name.--. .AT - - .... <br /> ddress ------------ <br /> - ---- ----- CZi <br /> Contractor'sName---- _ --.License .....Phone_ <br /> M.... � <br /> . <br /> stallation will serve: Residence ❑ Apartment House ❑ CommercialTrailer Court ❑ <br /> V Motel ❑ Other----------------------------- ----�. ,--- / + <br /> Number of living units;............._-Number of bedrooms----------- Garbage Grinder__..-_.-..-lot Size.-/O <br /> 'ater Supply: Public System and name.......-..........._---------.........._....------------..-.-.....---------------'-"----------------------------..._.Private <br /> haracter of soil To a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam-f` Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ FilfMateriai.- -_ ---.If yes, type_.......................... <br /> Mot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) S <br /> NEW .INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,)6. �/� C <br /> aCKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.-# ..-Liquid Depth /" <br /> Capacity _(.kqo.... Type..— <br /> ype.. t Material----- Compartments.-.- <br /> / -' jo <br /> �- - - ....__Distance to nearest: Well...... --._._..............Foundation---------- --------- _.P`rop.�jne.......---------- <br /> ff <br /> �' [ ] No. of Lines _---------2............Length of each line.--.--.---8d.............Total .. _......._-.".edo.......... <br /> . <br /> q r, <br /> rt'� D' Bo,* aA ype Filter Material,5a, :.' 4dv Depth Filter Material---------...__� '. .......... ............................. <br /> DistanceVVto nearest: Well... 0..244 -._._Foundation....._....._.._...____-.-Property Line----.___..____-_--_-----_-.-.. <br /> SEEPAGE PIT -- --- - — - - - - <br /> C l -Depth.---.._--...Diameter....'.--'---.-----Number----.......-'-'...--..-.-. � --- -Rock Filled Yes-W <br /> No 0 <br /> Water Table Depth --'------ ----------------- -------------------•-----Rock Size----L-1 <br /> L Distance to nearest: Well-------------------------------------------Foundation..............-....._---.Prop. Line---------------__........ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.-_.--.-_-__._----------------_. --------- Date....................... ---------___._-__) <br /> i <br /> `ptic Tank (Specify Requirements)---- - - --.-..--.-..-.---�---- - ------ ------ <br /> Disposal Field (Specify Requirement ) � J' " " """i """" - - a�%�� P � <br /> - - - <br /> r , <br /> 11,a( D - ------- ------------------..._..--------------------------- -------.------------- --_------------ - <br /> 6. <br /> ..... - - ------_. _' ----' --" -- ------------ -------- -------- -- -------- '-- ... -----------------------------------.-..-..... <br /> (Draw existing and required addition on reverse side) <br /> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 6.•dinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> r. become subject to Workman's C ensation laws of California." <br /> r <br /> ....... - ' ,Zz7ten <br /> .... -. - ------- - -- -- -- -- Owner <br /> Signed- <br /> ..... Titl <br /> ---------------- --- <br /> e _--- <br /> (If ... - - ... .... <br /> owner) <br /> FO DEPAR MyyENT USE ONLY <br /> r,PPLICATiON ACCEPTED BY------- - _..-.... . ��r --................. ...... .'-' ....DATE ------- <br /> DIVISION <br /> ----DIVISION OF LAND NUMBER.----------------------------- --- .................... DATE------------------------------ ----_-------- <br /> COMMENTS................................................... - -- --- <br /> ------------------------- <br /> ... <br /> -------------------- --------- -----.. <br /> ---------------------------------------------------I.. ... - ' ...--'---......---:.......----------'-------._....---..._..-`............ -...... . ---------"-' -'_...... . .......... <br /> ...------...... ............... ... ..................... . ........ ---•---•- ------- <br /> - ._..------- ----- .. -------- <br /> _.....Date.-..aS l P jam.. ...... ... ....... <br /> � nal InsPectlon by:--------------------------------------------------------- - •----- ---- �.. . --- <br /> 6 13 24 SAN JOAQUIN'LOCAL HEA DIS CT F65 21677 REV. 7/76 3M <br />