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FOR OFFICE USE: FOR OFFICE USE: r <br /> APPLICATION FOR SANITATION PERMIT C U l U07 <br /> ------------------------------------------------ No.....------ <br /> (Complete in Triplicate) Permit <br /> --------------------------- ------------------------ -- / -/- 76 <br /> Date Issued_--.�' ...------- <br /> ------------------------------------------------ __-- This Permit Expires 1 Year From Date Issued <br /> 70 ? - 17 0 -03 <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 compliancq with County Ordinance No, 549 and existing Rules and Regulations: <br /> . . C��JOB ADDRESS/LOCATION--- ---------- -------- ----..... CENSUS TRACT <br /> Owner's Name.----- - - ------ ----- - ------ --- -------------- - ------------------- --- Phone <br /> Address. - 04-----• h - --- --� City- --------- -.Zip------------------------------ <br /> r <br /> } � -.-_License #rX1� f: - Phone-_y,�5 - <br /> Contractor's Name----- -- - - _- -- -- --- -- <br /> el <br /> Installation will serve: Residence 0 Apartment Hou Co mercial E] Trailer Court F] i <br /> 'Motel ❑ OtherX <br /> I <br /> Number of living units:___ /.....-:"Number of bedrooms------------Garbage Grindes------------Lot Size_'ro�- D__ --- <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, type__-----.___._------------------ <br /> (Plot plan,,,showing" ize of lot, IocationAof'system in relation to wells, buildings, etc. must be placed on reverse side.) 9 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ', <br /> PACKAGE TREATMENT [ ] SEPTIC TANK (� /�ASi,,ze- ---------------------------------------------------- --Liquid Depth.- ----------------- <br /> Capacity f ___--Type---4e_ 1_Material.00;lQ_1_.---------No. Compartments.-----Or----r-- ----r----- <br /> Distance to nearest: Well_. ...._....................Found tion_. .-1J- ------------Prop. Line---��------ <br /> -- <br /> rY..!-ib' <br /> LEACHING LINE [}i� No. of Lines--------- --- ----- of each line 7-1 ( ---- otall Length.. ---- t4 <br /> 1 � 0� 'D' Box----------.-Type Filter Material_S,_e� epth Filter Material-----/-�..---- <br /> ------------------- ---- -�---------------- <br /> j <br /> - ----------- " <br /> Distance to nearest: Well.f_ .t�.-.•"r.�/_--------Foundation.-.._. .- ___.......Property Line_._-- <br /> / .....____----------- <br /> [) <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 /> DisposalField (Specify Requirements)----- --- ----------- ------------------------------------------------------------------------------ ------------------ ------------------------ ----- <br /> -----------------------------------------­ <br /> ----------------------------------------------- ---------------------------------------------------------- ------------------------------------------------------------------------------ -------------------- <br /> -------------------------=1------------------------- --------------------- ---------------------- ------------- <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 following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become jettk an s ompensation laws of California." <br /> ____ ___ ____o <br /> Signed. _ _ _________-. ___..Owner <br /> � <br /> By-------------------- --- -- -------------:----- ------------------------ Title------- - -- -------`- <br /> - --------------------- ------------------- <br /> r(lf-other th n owner)' <br /> ' FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B --------- -- ---- --- ------------------- -DATE._./a�-------- <br /> DIVISIONOF LAND NUMBER--- ---------- - ------- ---------- ----------------DATE------------ -----_---------- --------------- - <br /> ADDITIONAL COMMENTS---------- ------------------- - /---a ----------------------------------------- ---------------------- ------------ <br /> - ----------------------------------------------- --------- <br /> 4 <br /> --------------------------------------------- <br /> ---------------------------------- - <br /> -- --------------------------------------------- <br /> ....... ............ -.__ 6.... _ .......-----...--_----.-......------------------------------- .----...---- <br /> Final Inspection by: ----Dat - ---------- <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3m <br />