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FOR OFFLGE SE: ;.,,,ppLICATION FOR SANITATIC;N PERMIT FOR OFFICE USE: <br /> I (Complete in Triplicate) <br /> Permit No..�g:.��_ q <br /> l <br /> - -- ------------------ <br /> --------------------------- Date lssued_./=%_-7�' <br /> _______________________________________________________ This Permit Expires 1 YearW6i4 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 V 7 f A-"�_ -- -----�-�--------------------------.CENSUS TRACT ---- - - ----- ------- -- - <br /> a, ss -(�-� <br /> Owner's Name. <br /> `'l ----------------------------------------------------Phone_ _'' z-Z <br /> Address ' --Cit .l.,e .- --- Zi - --- -- ------- <br /> Contractor's Name._------- - ..:- W --------------------License #_a�__'f._3�_T'__:Phone.- (� ��- -- <br /> Installation will serve: Residence ❑ Apartment House.❑ Commercial 0 Trailer Court ❑ <br /> Motel ❑ Other----.-------------------- <br /> Number of living units:.---- .,. Number of bedroom.°s.._--.......Garbage Grinder___'_::-:__.Lot Size_.._____.____..._----------------------------------------- <br /> Water .Water Supply: Public System a:nd,name----- ----------------------- :_ .__. s., .. ------. ----------------------------------------------Private ❑ <br /> a, <br /> Character of soil to a depth of 3 feet: -',Sand ❑, Silt:°:❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe [] "Fifl Material-----------..If yes, type----'----------------------__._-- <br /> t <br /> (Plot plan, showing size of lot, location of sy._steni in relation to wells, buildings, etc. Must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank.:.or seepage pit permitted if public sewer iL available within 200 feet,) _ Q <br /> F , s k er <br /> PACKAGE TREATMENT [ j SEPTIC TANK size----- _ _V--------------------------------------Liquid Depth._�_�._._._.__._____� <br /> Capacity --------Type------- -----Material--- -----No. Compartments-----------------�----------------t <br /> Distance to nearest: Well------- �_:--�._--._____--___._Foundation- -!.��__________.Prop. Line_;;�__._______________- <br /> LEACHING LINENo, of Lines-_--_o --=---------------Length of each line. Q_.. ._ r�-____Total Length------ _ 7___________._------------ <br /> 'D' Box._.__k,r_Type' Filter Moterial_9 ---Depth Filter Material-----Z�%---------------------------------------------- <br /> -- <br /> Distance to <br /> nearest Well-__-_ `Q '�` _Foundation_____.__.rQ._�_.___.__.Property Line-----'�---�'--------------- <br /> SEEPAGE PIT Water --Didmeter----_. _.� .___.Number.:_.-_ _.__ -- Rock Filled Yes No El <br /> i <br /> fi i <br /> - -------------------------Rock Size-- � �f-- --�'"----------_.:.:�------ <br /> Distance <br /> -:, - � <br /> ---.Foundcftion-----lb-14- - - <br /> Distance to nearest. Weil_.�----lQ.�---�--------_-__-- '�---- ..Prop, Lihe---.:, -------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__________________________________ f _ _ ___ __-----) '� <br /> ----------------Date".---------------- - <br /> Septic Tank {Specify Requirements - - _-_- <r - ------ <br /> ----------------------------------- = <br /> Disposal Field (Specify Requirements)--------------`-------- ..-----=-------------------------------- -------------------------------------- --- ------------------------------- <br /> ------------ <br /> s <br /> F f <br /> ---------------------------------------------------`-._------..--._---_---._._...--._.__.____------------.- -------- <br /> (Draw existing and required addition`on side♦ <br /> hereby certify that I have prepared this appJication 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 per is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workman'si; Compensdtion laws: of California." <br /> II _ <br /> Signed ---- -------- -- Owner f: <br /> ,;,41 f othee than owner) <br /> }. <br /> F R DEPAXTNENT.VSE ONLY <br /> .:":,-1 <br /> APPLICATION ACCEPTED BY- ------- - - - �� . _: :. - ---=-: -- ---- -------------------- -- -- - -- - ------ - <br /> DIVISION OF LAND NUMBER------------------ - - --- ------ ----- --- ---------- --------------------------------------DATE - ' '= ----------------- --- ------- <br /> ADDITIONAL COMMS TS- --- -- <br /> -�. ------------------------------------ ---------------- --------------- - ----- <br /> --Rit�l <br /> ---- - -- --------- ---- ---------------------------- --------------- ------------ ------------------------ --------- 1/� <br /> Final Inspection by:--- -------------------------------------------------- _Date -----�� �jl ( ............ <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 24677 REV. 7/76 ane <br />