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FOR OFFICE USE, FOR OFFICE USE: <br /> APPLICATION FOR SA„NITATI.ON PERMIT <br /> (Complete in Triplicate) <br /> - Permit No...... _ ` <br /> *;.- .................................... Dote Issued..-�� <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.i.nstall the work herein described. <br /> This application is made in compliance with County Ordinance,No.549 and existing Riules and Regulations: <br /> I <br /> JOB ADDRESS/LOCATION./S7 ...../I!.=._... ct6 .._..W...........:......�4 --_-.:...CENSUS TRACT....._...._:..._ ._.. ' <br /> r ��++�� -----.. <br /> Owner's Name.... 141.t�•.. . ..-- .L.+Q ; .1 ............ ........................... Phanerz� '-. �! ._... <br /> `, ��--•• / <br /> Address - ,$� ... ,:..1.�s�,Cy. .......... ........Zip. .t!"�?. - <br /> _. <br /> Contractor's Name........ .........License #-._ Phone.......:....... <br /> Installation will serve: Residence Apartmenttouse❑ Commercial❑ Trailer Court ❑ <br /> Motel ❑ Other,................... ; <br /> Number of living units:. ,........Number of bedrooms,r.-I. {Garbage Grinder;jf ..Lot Size ........�lJ.._ C <br /> Water Supply: Public System and name_- .,......... ................ . <br /> ._ .,............. :.._.._..,..........................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ • Clay❑ Peat❑ Sandy Loom [3 Clay Loamg <br /> Y Hardpan`d Adobe.E] Fill Material . ..`......1#yes,type................................ <br /> (Plot plan, showing size of lot, location of system in relation to well3,buildings,etc.must be placed on reverse side.) ' <br /> NEW INSTALLATION: r(No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] ' SEPTIC TANK [ I Size.....`.. .��.,t�:� Liquid Depth'-��;��...G. <br /> ' aC0padtY,M.9d......Typ-qj&rAb.... Material:6.1 No. Co mportments_. Z.A .... ............... <br /> ._ <br /> Distance'to'nearest:Well.... .../..,,�"'D.. .... ... . .. r Foundation..-/Q. . - -:.Prop. Line.__ -•. <br /> LEACHiNG LINE [ ] No. of.Lines... Length of each fine.?_ t . "` Total Length _. . �, � 1 <br /> •• _.. /� / <br /> D' Box._J......Type Filter Moterial6B.'��ll'4.;e?X. Riter Material_._.. /Y-• •--•••••--•-.......•........ •...... <br /> Distance to nearest: Well,.•IS��I"......Foundation._. ,0 r'7�"�.____.Property line...�..__�'............. <br /> f lc <br /> SEEPAGE PIT [ [ Depth. .._..Diameter.. Number..... .._ ' -e Rock Filled Yes ❑ No d <br /> Water Table Depth.......... ............ .......... <br /> ..Rock Size..�l.y ". '•-- .Q <br /> Distance to nearest: Well........ d...4...............Foundation.../)?.�.*.-..: Prop. Line... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................................... ....Date........:..................................... <br /> l <br /> Septic Tank (Specify Requirements)..................%........................-.._._ ............... ........ „;.,...........:.................... <br /> Disposal Field [Specify Requirements). .......... .......... ... ...,.._.__...._........._........... .. .._..,......__........ ...... .. ... <br /> :. . ... ..... ._..­,......................... .,. . .:................... <br /> .............................. <br /> ..._._ ........_� ...............--------------.................................................-..---•--•------------..-.-..........------ <br /> .-........ <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 Son Joaquin Local: Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, I shalt not employ tiny person in such manner as <br /> to becom�ject to Workman's Compensation laws of California." <br /> ,, L <br /> Signed.'�,�I .... .....,� Owner <br /> ................. .................. <br /> Of other than owner) <br /> UM DEP TMENT USE NLY <br /> APPLICATION ACCEPTED BY.:........... .. ,... DATE -��. - ---- <br /> a `....._._�.._.. ..._. <br /> D.IVISION OF LAND NUMBER............. . ...... . DATE-----------......... ...... <br /> )DITIONAL COMMENTS. .............. ............. ,.. ._... _ ................_....._.............---........ ..... ............... . <br /> .................................. ................... ....-------------------------------------._...-• ...-•-•- •---.....----................... .......... ........... . <br /> ..................•••........._............ •------ ---•............................w... - <br /> _. <br /> Final tnspec-rion b ( .......................Date.. ... ...1��,�" _ <br /> E" 's 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV.7/76 9M <br />