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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 1, Permit No._71'­�.f$%'/,-- <br /> ------------- (Complete in Triplicate) <br /> -------------- ---- ---------------------_- i <br /> Date Issued-ZD_-P2�?75 7 <br /> ry hispPermit Expires 1 Year From Date Issued - .. <br /> -_-_• - <br /> ----------- ---- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> f This application is made in compliance with Cou ty Ordinance No. 549 nd existing Rules and Regulations: w <br /> -- -.- <br /> JOB ADDRESS/LOC Ill----- --- ---------- SUS TR CT <br /> -- ------------------------ <br /> i <br /> Owner's Name- --- - -------- ---- ---- -------------- ---------. - <br /> - --- <br /> Address �/ = ' , _ o <br /> } Z 'T <br /> iC <br /> ity .. - iP- <br /> �.e, - - ` ,.License # � :5�_ Phone --- -�.S A( <br /> Contractor's Name- �. <br /> µ' - ;. . <br /> Installation wily serve: Residence [Apartment House. ] Commercial ❑ Trailer Court ❑ <br /> Motel Q ; Other--->------=------ --__ --- -------- <br /> eryr ,� <br /> Number-of.bedrooms.,-- er-------------Lot'Size-- '- - - ---------� <br /> -----Garbq e Grinder­----­- <br /> Number of-living units -.�; g <br /> Water 5u,pply: Public System and name -.- .-----.-------- ---- - -.----- ..-.,, -------- ---------- --,,_----Private <br /> I <br /> - ' -- e <br /> I Character of soil to a de 'th of 3 feet: ; Sand [] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> P <br /> Hardpan Adobe ❑ 1 Fill Material-----'--_--- <br /> If Yes,type_-_"-----=-------------------- <br /> I (Plot plan, showing size of lot, location of system in relation to wells, buildings,•etc.;must be placed on reverse side.) _ J <br /> NEW INSTALLATION:— (No' septic tank.or seepage pit permitted if'public sewer is available within 200 feet,] x <br /> ✓ S/ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1. Size---�l`_-J�- ---------- ------------ Liquid Depth.-------------- 0 <br /> o $--No. Com attments------__- --a.2-.------ -------- <br /> Capacity/AP-4)­.- <br /> �- - °TYPe = _` "=-Material p . <br /> f Foundation_- - Pro Line_-- -.-----:-"- <br /> �.'. ..Distdnce.to nearest:"WeII_��Q� ----- --- --- / t----- ---- < p <br /> d------------- <br /> 0 <br /> -s - <br /> LEACHING LINE ( -_,No._of Lines_._ _ - <br /> :----Len,gth_of each-line �-��-.__,----- '------Total,' <br /> ---:Total,' Length / -- -- - -- --- <br /> --- ---DeP th,Filter MaterialJ------/0--------------------------------------------------� = <br /> D' Box-- :_T a Filter Material.511804kFoundation..OZ -/---------- ---Property Line------—----- ------------------ <br /> Distanceto nearest: Well--V66 _. . <br /> s.s ._ .- N <br /> SEEPAGE PIT [�. Depth--- - -----Diameter--' �----------Number--------- ------------------- Rock Filled Yes.�' Y No ❑ <br /> Table Depth--- <br /> Water =I-D --------------------------- -- ------------------------------ <br /> Distance to nearest: Well.*_," _ -!-------------=--F---Foundation.__l�_ "-I----. Prop. Line-_ --= <br /> . - <br /> REPAIR/ADDITION (Prey. Sanitation Permit#- ------`--.._---=--'---_-=- Date------ = <br /> ----------------- <br /> Septic Tank (Specify. Requirements)----------------- ---------- - -------------=- '--------=----------- ------------- ------------------------------------------ --- <br /> Disposal Field (Specify Requirements)---------.----- ---"---- "" <br /> ---- ---------------- - <br /> ---- ---- - ---- <br /> ----- ,_ <br /> ----------------------------------------- <br /> T ' (Draw existing and required addition on reverse side) <br /> 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 becol ect to.Warktnan's ompensationlaws of. California._ € �� <br /> - l <br /> -- --------- ----.--O.w..ner <br /> Sign - --- -- i1 <br /> t•,t- <br /> j Title -- ------------ ------------ <br /> By- <br /> (lf other than owner)` <br /> -• <br /> FOR DEPARTMENT USE ONLY ' <br /> @APPLICATION ACCEPTEB 7. TE <br /> DIVISION OF LAND NUMBER------- ------------ -------- ---------------._DA •------ -----------_---- -.:-------- -- ------- <br /> zr ----------------- <br /> ADDITIONAL = <br /> COMMENTS- -------------------- --------_--------------- ------------ <br /> ------- ------------ -- <br /> ----------- ------------------------------------------ ----- <br /> - -- ------- --- _ <br /> -- ------------------------------------------- <br /> = // <br /> --- - �-- --------- -- -- - <br /> � <br /> Final Ins ection b -Date------ - --- -- ---- <br /> pY: -----==---- - <br /> EK 13 24 ; AN JOAQ IN LOCAL HEALTH DISTRICT F&S 21577 REV"7176 3M <br /> k' <br />