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FOR OFFICE USE _.... <br /> . . . .. -.."FOR ���iCE-USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------ ..................... <br /> {complete in Triplicate} Permit No..���.�33 <br /> � Date Issued.l.9.:X.0-.,78' <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 conMtruct'and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 . <br /> JOB ADDRESS/LOCATION.. �,T.g..v t ._..., ... . <br /> r CEN <br /> S Ph <br /> TRA <br /> CT. <br /> ~ oneOwner's Name._ . --.... ...... ............... .........•-- -- ------------------ <br /> Address-.. <br /> -- ----• <br /> Address---- ----- <br /> ........... ...City-.... ----.-- t ) ...----- ZIP -----------•-----. <br /> Contractor's Name__: .- .L�� ................ Licensi Phone.... /Q <br /> Installation will serve: Residence Apartment Hodse ❑ Commercial ❑ Trailer Court ❑ <br /> t otel ❑ Other.- _----------- -------------- --- <br /> Number of living units:...-J-----....Number of bedrooms.j.. Garbage Grinder_:.--.......Lot Size.--- <br /> . .....arc '.�-------------- - <br /> Water Supply: Public System and name................ .. ... " } Private [ <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat El Sandy Loam ❑ Clay Loam E] <br /> Hardpan ❑ Adobe ❑ Fill Material.. ...: ..-If yes, type....: .- m:.............. <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 [ ) SEPTIC TANK [ ] Size.. + -..�;. -J-�--.-:- :--- �- ------.Liquid Depth.....--- <br /> A.. .• <br /> I Ca acit Type-4 Material. : No'`Compartments------- -------------- <br /> P y-.I -�i 0 ---- --- -... <br /> Distance'to riearest: Well........... -- ---------- --- --Foundation ----4_._Z9...- . ......Prop. Line..-.- -r .....---....Q <br /> • <br /> LEACHING LINE ] ] No. of Lines -- ------------------- <br /> 'D' <br /> ---_.---------- .- g t <br /> I Len th of each line..--- Total Length . -_----...... ..••-• <br /> 'D' Box-.-.t/.....Type Filter Material Depth filter.Material. -�...................... .- --------------. ---~ <br /> A ..... ; <br /> p.- Distance to nearest: Well Foundation-... :.°= Property Line..... <br /> l /uw rt <br /> 4 ¢-..-_-- Rock Filled Yes [� No <br /> [ ] Depth/OW iameter--------------------Number:.~.. ----- ✓, <br /> Water Table Depth--------------------------------------- -----------------Rock Siie------T .---- .......------- <br /> ^ Distance to nearest: Well _ ndation ....... ..........Prop. Line... .---..... _...... <br /> Fou <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.................:.....------------ ---............Date---------`------------------- ----------} <br /> R � <br /> Septic Tank (Specify Requirements)------.. .......... <br /> Disposal Field (Specify Requirements)---------------------- --- ................. <br /> ------------ -----•--- = <br /> -----------------I-------•---------- ------------ --- ---- ----------------- -----.... <br /> -------------------- ------- ---- ----- --- -----.....---------- ----------------- --------------------- ....--...... ............... � _. <br /> (Draw existing and required addition on reverse side) County <br /> a I hereby certify that I4have 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 become subject to Workman's Compensation lows of California." <br /> Ir <br /> ..Owner <br /> Signed....------ - -- ---P ...........--- -- - - - - •;- ------ ----- -.By....... -•---- - ----- Title ------------ ------ -- - ----- <br /> Ir�han owner) <br /> iFOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY....-- DATE ..1� -- -- - -- - ---- ------------ <br /> --- <br /> --- -- ----------- <br /> DIVISION OF LAND NUMBER -------- ------------------- -.....DATE.... :... <br /> t ADDITIONAL COMMENTS--------------- - --- --------------.------- --- . <br /> ---------------------------------- -- --------- -------- --------------- ......... <br /> ­------------- ------------ ------ ..------- ---- <br /> i Final Inspection by:.....�- ----- Date.�8 _-2 T p RE ..7176... <br /> 'EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 2�G77 Rev. i��a 3M <br />