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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> (Complete in Triplicate) <br /> Date Issued-. :� -�.� <br /> .................... .`.._.=....i...................... This Permit Expires I 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 /> A <br /> JOB ADDRESS/LOC TION_A---------- v::-- -.--- L.!'../......._ .... °.. CENSUS TRACT_ <br /> Owner's Name.... .-- . ....... .. .. ............................--- - -...Phone.. _._...._.. <br /> L <br /> Address.._.�2_.. .21pX.....SLS...-----_- ............. ....... . . ....... .__. . ..._...City- .I,4W ....----moo .Zip.._�J`.��16-------- <br /> Contractor's Name....Alle4-----2a_.cll <br /> P. c.._.._ _-. _.....................................License #..._5d-.------..-- - <br /> - Phone..7W_ ;2.3G4 .- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other.. -- . . ._........... ... <br /> Number of living units:--..-/........Number of bedrooms...J.....Garbage Grinder._.. Lot Size------------------ <br /> '/__..... ........ <br /> Water Supply: Public System and name................__. ................._._..._.._.........._I.........-.---. -.----._ ----.-----------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat 0 Sandy Loam ❑ Clay Loam JK <br /> Hardpan ❑ Adoben 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1 <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [i(] _ Size-.r..f.�_Q-'1'__s .fir............._____...Liquid Depth.�...._....___...__._� <br /> Capacity. tN?_._....Type ......-------No. Compartments_ <br /> Distance to nearest: Well---. 4.a_.....................•......FoundationProp. Line---S7_.---.-_---- <br /> LEACHING LINE j No. of Lines-----%T.... .-----.---------Length of each line_. -----------------Total Length .. b_ -------- .------.__._ <br /> 'D' Box_:+ Type Filter Material-471 47-.... Depth Filter Material../._......... ------............................. <br /> _.-. <br /> Distance to nearest: Well...v'_-.Q-----------------..Foundation../al.__..__..__-. --Property Line...c5_�.......___...._.._.._.. <br /> SEEPAGE PITDe[ ] p ._........ Rock Filled Yes No <br /> th....-.._ --Diameter....................Number----.---.--.--.--- <br /> . <br /> WaterTable Depth............ -- ----------- -_ _---- -- -----------Rock Size----------------_-------------_----------•--- <br /> Distance to nearest: Well..---------- Foundation..........................Prop. Line---- ---------.............. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- -----.Date--_ _-------- ------_...-....._------_.._-..) <br /> Septic Tank (Specify Requirements)--- - --------------------------------------- ------- ------ ---------_-_----- ----- - ----------- --..._..-._.. <br /> Disposal Field (Specify Requirements)------ -- --------- .. ------ - -- ------ ---------- ---- ---_-- <br /> ------------------ ------------------­-------- . ..... --------------- ------------ ............ - ----------.....-------- <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--) _Owner <br /> By----- ------------ -- ------- - -- __ ._ Title . ............. ----------- --- --- - --- <br /> (if <br /> -(If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...-,#....... .. . ---. .......... ----_---------- -- __ ---..... ....... ........DATE �. ��`J) ------------- <br /> DIVISION OF LAND NUMBER.- --------•-- - - -------------------- ---------DATE.- ------- --------- --- ----.._. <br /> ADDITIONALCOMMENTS----_---- --------•-•-------------------------- -------- ---...------------------------------------------ <br /> ---------------- ...... -------- ------ ---------- ------ ------..•-­---------------- ------------......------------........... ----------------- --- -- <br /> ---------------------- -----...---------------- ---------- ------...--- -----------•--------------- ------ ---- <br /> - D---te----.---J--�-- <br /> Final Inspection by:.... - - .... <br /> . <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F$5 21677 REV.7/76 3M <br /> r. Y <br />