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FOR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .,7. <br /> Permit No,.. ��J& <br /> (Complete,in .Triplicate).Triplicate) .. .. 3..... <br /> ----­----------------------- .............. ....... <br /> Date Issued._3.t'"J_-_,/.Z <br />. ............... .......... ................ This Permit Expires I Year From Date Issued I <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and Linstall the work herein described. <br /> This application is made in compliance with County Ordinance No.-549 and existing Rules an Regulations: <br /> JOB ADDRESS/LOCATION.... . ... _oo ...... ......... Ne-) <br /> . ... .... .... CENSUS TRACT........................... <br /> . . ... ... . .... ...... <br /> d.­ <br /> Owner's Name. -2.4 <br /> - ---------- <br /> Address...................... ....... ........._Cit ........... -------------_---- <br /> Contractor's Name._ ... ........License - 3 <br /> -- --- ---- Phone <br /> Installation will serve: Residence 2q, Apartment House 0 Commercial E] Trailer Court ❑ <br /> Motel ❑ Other--- ------ - --------------- <br /> Number of living units:--------/-.Numb'er of bedrooms.-0. 2- Garbage Grinder------------Lot .................. .. <br /> Water Supply: Public System and'name........................ 44P---�. .� ............. ------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt[I Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loom ❑ <br /> Hardpan EJ AdobeX.- 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 pL;blic sewer is available within 200 feet,) <br /> A <br /> PACKAGE TREATMENT SEPTIC TANK <br /> 'f i ze.. --------------- <br /> Capacity/,R .0-----Type- Ae. . .....Mater _�'___No, Compartments..-.....:.---------Liquid ---C4 <br /> .....Mc i016�- ...---- <br /> } <br /> Distance to nearest: Well-_ _Foundation Prop. Linel-.-* f <br /> LEACHING LINE [410"No. of Lines ....../................. Length of each line, ------- -- Length ....Total <br /> ---------- ----------------- <br /> D' Box...'.- -.Type Filter Materiawl. Depth Filter Material. ----- ----------------- ------­­­­------- <br /> Distance to nearest: ..Foundation--_A 4�...............Property <br /> - .. . <br /> , 0? -.1 .. ......... --- --- <br /> SEEPAGE PIT Pr- Depth 4;�15 .....Diameter.. _�P--- ---Number.......I/..----------—--------- -el Rock Filled YesX No <br /> Water TableDepth.----- _ ---- R6ck Size_ ; .. -------------•. ......-------------- - <br /> � ....Distance to nearest; Well_ 1 ...... -----Foundation..74 -- -. Prop.'Line <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................. .................................Date.............................. ------- <br /> SepticTank (Specify Requirements].... ------ --------------_-- -----------------_------------------------- ............................ . ..... . -------- <br /> Disposal Field (Specify Requirements)- ............. <br /> .. ......... ......... --------­­­------ <br /> f <br /> ----- - -1-------------------------- ......... <br /> ------------------*--------------- -------------- ------- <br /> ------------------------------------------ ---------------------------------------------------------- ---- - ---------------------------------*....... <br /> ........................... .............­............ ------------------------­_...................................................... . . . ---- ---- ----___.......... --------------- <br /> (Draw existing and required addition on reverse side) <br /> 0 <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 San Joaquin Local H"Ith 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 Wo kmon Msompen ation, laws of California." <br /> Signed------- .... ..... ... .. .... ------- - ------ - Owner <br /> By----------- ---- ....................................... Title_. ----------------- ------ ------ vi <br /> (If other than owner) <br /> -tF9!:DEVARTM0T USE ONLY <br /> APPLICATION ACCEPTED BY..-------- <br /> 7 <br /> a1dA..................... _ � --- <br /> /� DAT� <br /> DIVISION OF LAND NUMBER.-----.-....... .- ...... - ---------------------__-----------DATE -- <br /> ADDITIONALCOMMENTS ..... . ......... ............ ---------------------------------------------------- ........................ ............ ...... <br /> ­­ --------------- ........................... ......... ------- ....... .......................................­ I ................. --------- ........... . <br /> .......................­­............ - <br /> ------------­- ----- --------------------------------------------------------------- <br /> ------- ................................. ...... <br /> -------------------------------- - ......I...................... -------------- ----------- -------- ---- -- - - - -------- ------------- ------- . ................ ......... <br /> Y <br /> Final,Inspe:cfion by:.................................. ......... ------------------------------ --- Date... <br /> EH13 24 SAN JOAQUIN LOC��HEAL5THDI TRI F&S 21677 REV. 7/76 3M <br />