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FFOR OFFICE USE; <br /> OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � <br /> ------------------------------------------------------- <br /> (Complete in Triplicate) Permit No.7-g' .�-Y-- <br /> --------------------------------------------------------- <br /> Date <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 compliiance with CountyOrdinance No..549 and existing Rules and Regulations: <br /> �B ADDRESS/LOCATION- -rte t -----.�+_.... 7. a.Ao.�.L tv\D..�------------------- ----- ---CENSUS TRACT. i <br /> Owner's Name_.rOS--�---- + . . US- ... Phoneg <br /> 2.3 <br /> ---------------- -- -- -- ----------------------------- �y <br /> ddress j- .. {.L7-,... rCLL.(� --�.a-11� e---------- ---------------- City--Trac.................. --------zip-9,5.374-------- -- <br /> ontractor s Name---sle- ----------------------------------------------------- -------- - <br /> _.License #- ------- ---- --------Phone--$ 13 7715'-- <br /> Installation will serve: Residence k�j/ Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other------ -------------------------------------- <br /> Number of living units:_.............-imber of bedrooms.-3_----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 ❑ Fill Material-- ---------If'yes, iype--------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public.sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth_.------------------------ <br /> Capacity------- <br /> --._.-----_----------Capacity------- -------------Type--------------- -------Material. -------------------- ---No. Compartments--- ------------------------------- - <br /> Distance to nearest: Well-------------------------------------- ----Foundation-----------------------A,Prop, Line---------------------------. <br /> LEACHING LINE [ ] . No. of Lines------------- -.....Length of each line------------------------------Total Length----------------------------------------- <br /> D' Box-----------Type Filter Material--------------------Depth Filter Material----------------------------------------------------------------- <br /> Distance to nearest: Well----------------------------Foundation----------------------------Property Line.---------_----------------------- <br /> SEEPAGE PIT [ ] Depth-----------------Diameter--------------------Number--------------------------------- Rock Filled Yes ❑ No❑= <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 /> ----/----- -- -------------------------------------- -------------------------------- <br /> Disposal Field (Specify Requirements) .': -- ---fV-----!` Q -------------------------------------------------------- ---------- <br /> ----------------- --------------------------- -------- -------------------------------------------- --------------------------------------- <br /> ------------------- ----------------------------------------------------------- --------------------------------------------------- --- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 /> >$gned �� --------------------------- --- -----------------Owner <br /> �J <br /> By- ------------------------------ -------- Title <br /> (If other than owner) <� <br /> ORD TME T U ONLY <br /> APPLICATION ACCEPTED BY--- ---- - --------------- DATE. r ------- <br /> DIVISION OF LAND NUMBER-------- --------- ---- DATE - -------------------- -- <br /> ADDITIONAL COMMENTS.- <br /> --- <br /> �^'; - -------------- -------------------------------------_---- ----------------------- <br /> -- --- ------ - <br /> -------------------- ------------- -------------------------------- ----------- = ---------------------------- --------------------------- <br /> -------- -- <br /> -- ------------------------ -------5 -- --- ------------- <br /> -------------------------------------- -- <br /> Final Inspection by:. - ---------------------------- ---- ---------- Date _ Z_ - .��1 <br /> EH 13 24 SAN JO IN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 <br /> 1 - 1 /r <br />