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FFOR OFFICE USE: <br /> OR OFFICE USE: <br /> li APPLICATION FOR SANITATION PERMIT <br /> --------------- - - p p ? —3 <br /> - � � ----i (Complete in Triplicate) Permit No.---- <br />` --------------------------- ------------------ s- .� 3 7,P <br /> 11 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 /> k JOB ADDRESS/LOCA N ,57 <br /> T -_ "' ' ------ <br /> ------ <br /> --G ---- -- CENSUS TRACT-- <br /> 11 ,�� v <br /> l Owner's Name_,-�- _ = Phone.---- - <br /> Address I ° Cit ----'Zip-- <br /> 3 — _---- ------- �!� ---- -- ---------- --- - -------- - �. '•� �� <br /> Contractor's Name.,.. _�_-- +-Gr.__� -- --------------------License #_-3o5] ___-_Phone_cz- ------------"----- <br /> Installation will serve: Residence E!,Qpartment House❑ Commercial ❑ Trailer Court ❑ <br /> Mote t -- - �- <br /> Number of tiding units----------:•9.----Number of..bedrooms_ __Garbage Grinder.-_ ------_Lot Size__:-..." ---- <br /> : -- ---------------------------� �--- <br /> 1 Water Supply: Public' System and name :. :--.--- -.:----R----- ------------= ,.,: ''-_---------r-----------------'--------------- :-------- Privateer , <br /> Character of soil to a depth of 3 feet: Sand-El.. hSilt_❑; ,Clay-�_i:Peat ❑ Sandy Loam ❑ Clay Loam ©— <br /> Hard'' 1 Adobe-F-) 'Fill-Material.___>--.§._If yes,type----- .._-______..._...__-- F <br /> , <br /> (Plot,plan;.show ng size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) # .A <br /> NEW NSTALLATION:' .(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ]' -- ---Liquid Depth.'_-5�' �� <br /> SEPTIC TANK '[!k'=h Size---_------' --�._F/�.= ��.t - -- ------------- ----Yr <br /> p Y,- - YP " o Compartments------2�fl--- <br /> tl e t <br /> i I <br /> r Ca acit t. -- T e._ Material._ --c2 1 N <br /> Distance to nearest: Well_-,OL5.-f---------------------- Foundation.- - j. --•------ 'Prop. Line.---------------------- - <br /> t <br /> .a _ _-. g L e' = U---------------[.Total Length.__ . <br /> LEACHING LINE. [tk .No. of Lines___._... Len th of each lin <br /> k 'D Box-I€ tt -Type Filter MaterlalJ�N41�� Depth Filter Material .'26�1 -------- -------_.-- --------------------------- -- <br /> T. <br /> Distance to nearest Well. 7� -- Foundation ---.-" _ .Property Line - ---------------------- - -- <br /> SEEPAGE PIT [ ] Depth---- Diamete`r._-,_-----�--=----Number-------------------- ---- Rock Filled Yes ❑ No ❑ <br /> / t <br /> Water Table.Depth-=- Rock Size ' <br /> `" . Distance to nearest: Weil--=------ --------------------'-....."...---Foundation_.,.._._ Prop. Line ..... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--'-:---_'.---------------------------------------=-----Date------------- ------------------.------=-----I <br /> SepticTank (Specify Requirements)------_-=- = �----'----------------------------------------------------I- ---- ------------ ===---------------- --------------------------------------- <br /> Disposal <br /> --------------_----- ---------------Disposal Field (Specify <br /> I ], RequirIements)---:--:--_'_ . > . -------i---------- ----------------- ----------------- <br /> ---- -- --------- - -------- -- ------------ <br /> --------------------- ------ . .. _ <br /> ------ -----=--- --- ------------------------ <br /> I <br /> ---------------.:-------.-...X---...- <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 San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the followirtg: ~ <br /> "Iertify that in the performance of the'work for which this permit isA'issued, l shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> i Signed = *oi�er <br /> r <br /> --Owner <br /> 7 <br /> 1t <br /> nowner) , <br /> :1 -FORDEPARTMENT USE ONLY <br /> .�- ..r .. - - ....__---M----------- <br /> APPLICATION ACCEPTED BY,-------- - ------- ------------------------------'----- ----------DATE-. �I9•�' <br /> OF LAND NUMBER --------------- ---= DATE ---------------------- <br /> DIVISION <br /> ADDITIONAL COMMENTS---=I------------ -- ---- ---- -------------- --------- ------------------ --------------- <br /> I - -------------- ---- ------ . ------------------------------------------- ------------------- -------- ------------- --- <br /> ----------- i <br /> f '' ---------------=------------------------ ------ ------------------------------------ <br /> 0 ----- - <br /> --...'----------------------------.__------.__-.. ___,_-.__ ..._._----------------------------------- <br /> ___...___- _,..__..._____-..... ----------------------- - _..."___..._..___ <br /> Final Inspection b ----------------------------------------------- <br /> EH <br /> — -- _ <br /> _ - <br /> Iff <br /> ' ----- -- ----------------------------- - ------------------------ <br /> Date-. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />