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FOR OFFICE USE: FOR OFFICE USE: <br /> ------------- '11110,0LPPLICATION FOR SANITATION PERMIT <br /> Permit No.... . <br /> oo <br /> (Complete in Triplicate) <br /> �Jr. . <br /> ------ <br /> -------------------------------------------- ------------ This Permit Expires 1 Year From Date Issued Date Issued.... _LL _79i- <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/LOCATI L� _ <br /> -- - - �-K. LN'�_-ft ,O-------------------- E US��RAR p <br /> Owner's Name - , <br /> --------------------------- ---�.�-hone. --01 -�------------- <br /> Address- -------- �- s - 4�M.t�s lte4.-c a------------zi , z <br /> s``yyrr-- A - L A� ty.._Q- --- -' - - P--- .�---------40-------- <br /> Contractor's Name--------- _/�'^IM�..{,,.p---------_License #_- 2,9Z-_ . ----..Phone-..-----_--_.------.-.---. <br /> - il'r"--tom-"'�- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commeff��ial ❑ Trailer Court ❑ <br /> Motel ❑ Other- ►sir ..�.... /fJra.j� <br /> Number of living units------ --------Number of bedrooms..----Garbage Grinder------------Lot Size-_.__---SAO---gw .-_----..._-__. <br /> Water Supply: Public System and name _..__--------------------------.•-_-__-.-------..._..-..---- . --Private [� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay-❑ Peat❑ Sandy Loam p Clay Loam ❑ <br /> Hardpan Z Adobe ❑ Fill Material----_------If yes,type-----------------__...____. <br /> A) <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.( O- <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer ,) <br /> rewer is available within 200 feet <br /> PACKAGE TREATMENT [ J SEPTICTANK [IS Size.�I - --X--7- - ------------------Liquid Depth -------------- -----------O <br /> Capacity ---....Type.. Material----- ------No. Compartments-------7�------------------ <br /> p, <br /> r <br /> JDistance to nearest: Well--------------SO_--_--_ i-.-- Foundation-------�1_--.-----_..Prop. Line.._-�.-.-------------- <br /> LEACHING LINE [fff No. of Lines-._____., <br /> ------------- of each line-------- r_{.p_--------------Total Length_.._.TXAV;;..-.....-.-..-.--- <br /> 'D' Box----- ......Type Filter Material.-----5.--X----Depth Filter Material--------f-g.... ._..:-._--------------_____---. <br /> / Distance to nearest: Well------- .-...-__-....-...Foundation---------JO--..--.-._..Property Line- ------- <br /> __..-.-.. <br /> .40 <br /> SEEPAGE PIT [t'J Depth.-Ls r_---Diameter-33----- Number--------3------------------- 1 4 Rock Filled Yes[ ' No❑(� <br /> Water Table Depth------------jloio......--.�--------------.-.Rock Size--.-..-- . . <br /> Distance to nearest: Well----------104)--/_---------------Foundation---- ....._----Prop. Line------- <br /> (Prev. Sanitation Permit#-------------------------- -----------__.--------Date--- ----------- ------------------------------) <br /> SepticTank (Specify Requirements)--------------------------------------------------------------------------------------------------------------------- --------------------------_--------- <br /> Disposal Field (Specify Requirements) ----- -- -------- -------------------------------------------------------------------- - _------------------- <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 /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed <br /> Owne/ n <br /> By --- 4. Title----r <br /> C <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--. -------------------------__-------- - -.DATE._--- ....--......_......_...._--..........-- <br /> DIVISION OF LAND NUMBER._ - -- --- - ----- ----- - ----------------------------------------------------------------DATE ..... ........- .. ------------- <br /> ADDITIONAL COMMENTS---------- <br /> ----------ADDITIONALCOMMENTS-------- --------------------------- ' ---------------------------------------------- ------------- ---- <br /> ----------------------------------------------------- -------------'----------------- ' - ------------------------------------' <br /> -------------------------- <br /> -­------------------ <br /> ----------------------------- -------------------'--' ' - ---- <br /> Final Inspection by:---------L._-�----. -..._---- -------- --- ----_....--------------------------------------------Date--�-�----- - ------ --- <br /> EN 13 24 SAN J UIN LOCAL HEALTH DISTRICT FLS 216] REV.7/76 3M <br />