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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No.7 � 6 <br /> (Complete in Triplicate) - <br /> Date Issued_/0-6-'_._ <br /> ------------__--------- ---._._ .......__-_____ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the Sani7oaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance Noo�.,5/49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION <br /> r ICQl/Y��`+- .4.34,x�-�`!'�. .... �,9. r---/ Ai- - _ CENSUS TRACCTn---------------------- _---_ <br /> Owners Name_-- - - ..-Y_Q(.C- .,L���1 -wf�O."G.t�Gtit+�� --_'- .......- _ _. .Phone.fs±./"� <br /> Address.- . _./`�' - s� ------ . ----------- C' -- --Zip ---- --- <br /> -7 Ifs-+�c 9ty ����&y-�-�,.. ��/ ` p� <br /> Contractor's Name- ----------------- -- ----- --- - - ------ - ------------------- License #�/t7..T.a7 -Phone-AA4b l& -------- <br /> Installation will serve: Residence ❑ Apartment House C] Commercial Trailer�ourf, <br /> Motel F-1Other- ---.------------------- --- ----------- <br /> Number of living units:---____-----Number of bedrooms-__-__ Garbage Grinder--------__ Lot Size--------- - --- ----------- - <br /> Water Supply: Public System and name---- --------- --- -------- ----------------------------------------------- --------------------------------------_-_--_----Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe TK Fill Material------------If yes,type.____--------- ------- .___ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) rf O <br /> r <br /> PACKAGE TREATMENT [ j SEPTIC TANK [� ize_-_._S-. //��jj-8-�---�---- --- --------- --Liquid Depth .s ----___------� <br /> Capacity---�-�' ------Type__ .---Material.l:rl!(GG No, <br /> _ C_ompartments------.,�---- <br /> -------------- <br /> Distance to nearest Well..-..--._L� '_� _____ --Foundation------ -- -------- <br /> - - <br /> LEACHING LINE No. of Lines....... ----------------Length f each line__.-_SSO..----- ------Total Length___LQn_-------------------- -- <br /> 'D' Box ---- Type Filter Material.- ---.-Depth Filter Material----/11__u.__---------------_--------------------- <br /> tt <br /> ! r <br /> Distance.toSr nearest: Well.-_--.LtrD-_-------_Foundation--._L_1?_-------------__Property Line__ --___-_-._..._.___. <br /> SEEPAGE PIT [� Depth---2 ___.Diameter_--��__----Number..__-__��----- ------ Rock Filled YesZ No❑ <br /> I-Y'1 / rr <br /> Water Table Depth-------------- -------- -----------------.Rock Size- - X y -------------------- <br /> Distance to nearest: Well----------- <br /> - - <br /> Distancetonearest: Well.-__-__../_ � - _ _ Foundation-.._.--(0!J-- -Prop. Line_. ----- ------- <br /> ---- <br /> .- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____--------------_-±------.--- -------------.--.Date----------------------------------.-----------) <br /> Septic Tank (Specify Requirements)------------ --- .. . -- ------I----------------------------------------------------- --- ------- ------ --------.------------------------- <br /> Disposal Field (Specify Requiremergsj-=------- --------- ------------------------------------------------------- -------------- ------------------- <br /> -------....._-------------------------------------._---�------=--`---------...------------------------------------------------------------------------------------------------ <br /> -------------------------------- - ------------------------------ -....----- ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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. - -- ----- - - ------- Owner <br /> By--------------- ---- ------ -. 4: Title------------ ----------- <br /> ( other than owner) <br /> FO DEPAR ENT US ONLY <br /> APPLICATION ACCEPTED BY-- ------ -- - — ---------------------------DATE .. �- - 7.g -... <br /> DIVISION OF LAND NUMBER --------------- <br /> - - ----------- DATE.. - --------- - --- --- .... - <br /> ------------- ------------------------ <br /> ADDITIONALCOMMENTS--------------------------------------------- =---._... ­-------------- ------------------ --------------------------------- ----------------- <br /> --- ---------------- - <br /> --- -- <br /> -- - - - -- <br /> ----- - <br /> Final Inspection by:... -°�------------------ te <br /> --Da -----\1!!-- �1�.� - ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTHY DISTRICT FrS 21677 REV-7/76 3M <br />