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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..---._--................. (Complete in Triplicate) Permit No..76-�� <br /> -- ir7 <br /> Date Issued---W:.1f�-- <br /> ........................................................... This Permit Expires 1 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 /> JOB ADDRESS/LOCATION-_/, _�.. _.�------- -- ------ ._ ---------------...--------- ...-----.CENSUS TRACT._. ...... <br /> yPhone............................ <br /> Owner's Name---- ---- .... �'�........ <br /> Address _.._...�. <br /> ............City----0 -4=... ;--•- <br /> . <br /> Contractor's Name.._. _ ..... - - ..............License:#=��,.?- -- ,-Phone. _.... <br /> Installation will serve: } Reside ce ElApartment'House❑ Commercial.❑ Trailer Court ❑ <br /> Motel ❑ Other..-.! . *-� <br /> Nu`mbe'r of living units:.._._.. -__-Number of bedrooms_._ _Garbage.Gririder....; ?>Lot Size—.------_---- ='-- r,{ -•••-• <br /> Water Sup Public System and name_.,_...._.. :•------------ ------- •---- :-.---------.t... v__...��:.......,.... ...:.....-, .... Private <br /> e ❑ <br /> Character of soil to ! <br /> a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpane Adobe ❑ Fill Material_....,..... If yes, type---------_--_----------------- <br /> (Plot plan, showing size of lot, location,of system in elativnl-t w 11s b ildings,'etmust be placed on reverse side.) <br /> +_. ._t..v '. <br /> NEW INSTALLATION:i i(No septic tan`K-.or see age pit permitted if public'sew/er is available within 200 feet,) <br /> PACKAGE TREATMENT,;T ) SEPTIC TANK [ " Size..7." ._------•------- •••••....Liquid P Depth---- -------------------_ - <br /> Capacity.� _© tType_ M`aterial_,rS`�' =.. ._..No. Com artments_ "�..................•.. ry <br /> a /y <br /> Dist6nce to-nearest:.Wel l.. .----------- . <br /> -�cc'___ c. Foundation.._._ 1� ..-.Prop. Line ._S ._ <br /> ___ _;___• .-___. <br /> - <br /> LEACHING LINE [` No. of Lines._._.__,_,._ ' <br /> .. ...... of`.each line._.,,_,.l` 4_ �-Total Lengthd �._....{._ . <br /> i * -41 f I-11y it <br /> T�D' Box.../-.....Type Filter Material------ .Depth felter-Matenal-- ---•-----------=-----=------•---••--_----••-- <br /> r f a� Property Line 3 <br /> -Distance to nearest: Well----- -__e�' __ _ _ __Foundation•.___ ..____ <br /> s Rock Filled Yes No <br /> SEEPAGE PIT [ �. Depth.__ Diameter-,... _3--.__--Number-..:___--------------------- <br /> A, <br /> Rock Size_ -�------'--•---------- <br /> f Water Table Depth---=...... ry-( _ � rt?--- --- -------- <br /> Line <br /> ------ < •� <br /> ► ' Distance to nearest:Well.......... •--;Foundation.__�le�~- Prop. Line__. _._____-___ <br /> REPAIR/ADDITION;(Prev. Sanitation Permit#.�.........................-----------------------Date_.__.--------------------------------------- - <br /> Septic Tank (Specify Requirements) ...............___-....--........... ------+ . ....................................... ----.......... ............. <br /> i • <br /> Disposal Field (Specify Requirements)-- ------------------- ---•-------_-------------•-- ..............,„......................•.................___........ <br /> ............ <br /> ! i s .................... <br /> -•---------•-------• = -+............................... ..........--------- ..................................-- . :---.---- - - - <br /> _ 1 . <br /> i <br /> ............_................................................... ..•_ ------------­-----.•--..---•-------------------------------•--------- <br /> ------------------- <br /> j } (Draw existing and Fequired addition on reverse side) ' <br /> {,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 I and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> i I <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 Co enjgg6! laws .of California.':- <br /> . : <br /> Signed------..:. - - --------•-- --- --- - L. -- - -----Owner <br /> f <br /> `` (if other thdri owner) ' <br /> 1 <br /> FOR DEPARTMENT USE ONLY: T <br /> APPLICATION ACCEPTED BY. ................ .........:...Dill.TE.--------------- ... <br /> DIVISION OF LANDS .........................: ...--- •DATE._... - . <br /> NUMBER._---•----- <br /> ........._ <br /> 'kDDITIONAL COMMENTS................:.._............. � ----- ---.------------------------------------------._...--•-... <br /> --------------------------------------------------------------"­...............:._ <br /> ----------------•--:.-...'_ - <br /> ,..._.�............................. ---•--.-_._..........._........__•__..........--------------------- - <br /> ---------- <br /> D - ---- --- <br /> Final Inspection by---- = ._' ..... .. > ate.:_.- -� <br /> fH 13 24 ( SAN JOA UIN LOCAL HEALTH DISTRICT Fes si677 aev. 7i76 am <br />