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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------- ----------------------------- Permit No13 /per a- <br /> (Complete in Triplicate} .17._ -._. _ <br /> --------------------------------------------------------- <br /> Date 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 install the work herein described. <br /> This application is made in compliance with-County Ordinance No. 549 and existing Rules and Regulations: <br /> r JOB ADDRESS/LOCATION-- J a' >.. 8= � --------- - i ..CENSUS TRACT - <br /> Owner's Name -----Phone- <br /> Address--------------- <br /> hone Address--------------- --------------- = = "---- '-------- - `r------------- ------ City . --- . ;�-----------Zip------ ------- -- -- <br /> ` �� _ <br /> Contractor's Name `f' --- ' icense .# 3 a ��' Phone <br /> s. <br /> Installation will serve: Residence ❑ Apartment House.❑ Commercial [Trailer Court. E] ; <br /> :• . .` -Motel F1 Other,. �. :.. ;. <br /> Number of living units: --_._____ : ~ <br /> Number of bedrooms------- <br /> :,_ ,Garbage Grinder Lot Size-.-.._ �______.___._ <br /> Water Supply: Public System and name_-------------------------------------------------------------- - ------ --- _..} --------------------------Private El <br /> Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay [�. w''peat r Sandy Loam E] YClay Loam E] <br /> i Hardpan❑ Adobe ❑ ' 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,) <br /> PACKAGE TREATMENT [ ] s SEPTIC TANK[W '_---___________________'_____Liquid Depth._---"-----._____._ ___ <br /> ,. .- Capacity- 'TYPe Material- -.No. Compartments <br /> Distance to nearest:.Wel l._:------------ �� -=----------------Foundation===---- .-- ---,---Prop; Line-----_----------------------- <br /> LEACHING LINEM1 [� No. of litnes,--=- r---_- _'- --:Leng"th of each line..,..-'..-.-=ty ---:---Total-Length.-=-:- --- <br /> -- ---------- <br /> D` Box---------- Type Filter Material.___Sf_ _ ____.Depth Filter Material___:___. ---------------------------------------- <br /> nearest-. <br /> -•-_: 1�G ' -,-- Foundation-----1-0- ------=---Property Line--------- ----------- '- <br /> &EePAGE PI DestYFnce two nearest�Weg l_ X 1s`J- �. . .. <br /> „ O s. <br /> [ Y P N _ Rock !i N <br /> Number .� __}. _ R Filled Yes o ❑ <br /> t <br /> Water Table Depth � / - RockSize;, -�� ' <br /> Distance to�ne�arest-lNele- '--:•--------- Pro Line-_--- -- -- -------------- <br /> -------------- <br /> --------- -- <br /> Foundation.._- . y _ p. �j — <br /> ` REPAIR/ADDITION (Prev. Sanitation Permit#--"-_: ------------------ - -- ------------------Date-----;-------:--.------_--------`------------- <br /> ---------- <br /> -----_---- <br /> I <br /> i t 4 <br /> Septic Tank (Specify Requirements)------ `' = . . . . - ---------- --- <br /> ---------------= = <br /> Disposal Field (Specify Requirements} - / `' .; t ----- -------------------------- -------------------------------- ---- <br /> � k <br /> — ,� <br /> S �• <br /> ------------- <br /> -----------------------------------------------_---------------------------------------------------------------------------- _____ ------------------------------- <br /> (Draw existing and required addition on rever�a side) <br /> I.hereby certify-that 1-have prepared this and"that-the-work-will-be-done-In-accordance with -San4Joaquln County <br /> Ordinances, State Laws, and Rules and Regulations of_theSan Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: " 4 T <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 /> Si gned = -------------- -----------------. . Owner <br /> �/Xi <br /> BY ' = - '` �;Z Title ---------- --- :..__. <br /> (if other than owner) } <br /> DEPARTMENT USE ONLY <br /> -FOR DEP �. .. .r. .... ., .. <br /> LICATION ACCEPTED BY -------------- ---- - ----- --- -- -- ---DATE . G -- -- , . <br /> APP = . <br /> DIVISION OF LAND NUMBER` __:- ' DATE ' <br /> . . . - <br /> ADDITIONAL COMMENTS----- ----------- -- --- ._ --: <br /> a ---------------------- <br /> --- _ -----•--------------- --• ------ =----- ------------------ ---------------------- <br /> ----- -- --- - --------------------------------------------------------------- <br /> ---•- -- ' - - - --------- <br /> Final Ins ectiombY --- -- � ate ----------------------- <br /> ------- <br /> - ---- <br /> 1`- EH 13 sa SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F&s 21677 REV, 7/76 3M <br />