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FOR OFFICE USE: ! FOR OFFICE USE:' <br /> APPLICATION FOR SANITATION PERMIT 1 v <br /> I <br /> ------------................................... Permit No..7f. -/�..... <br /> (Complete in Triplicate) <br /> may) Date Issued..a <br /> :([.a._.�.......__.!:.................. This Permit Expires 1 Year From Date Issued <br /> Application is he made to.'the San Joaquin Local Health District for a permit to construct andInstallthe work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existi`ng Rut nd Regulations:CENSUS TRACT_'— <br /> . ........ <br /> I JOB ADDRESS/LOCATION..,.. ....I ....- -..... .. _ .._ ...-.l'lj <br /> I Phone <br /> Owner's Name..: ....... :.....................: <br /> Address---....: . .>�:....:.. -- -- --- � -. .....'.--••------- City � Zi ...-......�`T� . <br /> p ...... ........ . ................--: ............_.._..... ... iP < <br /> Contractor's Name..._...:.............:... :... ..:. .,...License #_, Ba(. ...... ..:,.Phone. ..� . <br /> Installation will serve. Residence Apartment House E] Commercial ❑ Trailer Court ❑ . <br /> l Motel ❑ Other....... ...............-.................. . . <br /> Number of livirig units:......1:......Nurrer ofbedrooms... -_.Gorboge Grinder.............Lot Size------- -e.dV-. • <br /> } <br /> Water Supply: Public System and name.............................:....................... .............................:............................. :. Private , <br /> Character.of.soi I to a depth.of 3 feet: J Sand [] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Cloy LoamA <br /> ,Hardpan ,. Adobe Fill Material.. .... ....If yes, type-----------................... j <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse.side.) <br /> i NEW INSTALLATIO14: (No septic tank or seepage pit permitted if public sewer is available within.200 feet,) _ <br /> PACKAGE TREATMENT ( ] SEPTIC TANK . [( ] Size...... i... x 1.�--• -Liquid Depth.. ................�� <br /> ' •- --- <br /> `' Capacity../ .. �-Type.......... ......Material._ . No.`Compartrtzerits...... <br /> ` •--....... <br /> � ..._....: �. R <br /> - • ,.t•"'Distance to nearest: WeIl.......1JP ...... . . .... Foundation_.4.Q . ..............Pro <br /> P • <br /> LEACHING LINE [,] No. of.Lines ...--.I.................Length of each line..... .7......... -------Total L�eigth .•/---��,?.....---_-.... <br /> ' D' Box; ¢,Type Filter Material.....1.1 Depth Filter Material... ........ ......_.._...__......;-........ <br /> QQ �� <br /> -r <br /> Distance to nearest: Well............... ........... Foundation.............. ........Property Line....... ............. <br /> SEEPAGE PIT ( ]• Depth---IZ-.8^Diameter...e.'�.........Number....�4..........I............ Rock Fiiled Yes <br /> WaterTable Depth................... ..•-- ............-_ •. .......-.-.Rock Size.................................I-.............. <br /> Distance to nearest: Well......F. tp.10......................I Foundation..........................Prop. Line_.._................ <br /> REPAIR/ADDITION (Prev. SanitationPermit#-----..........._.................. ...............Date........:------- -I.............. ---- -) I' <br /> Septic Tank (Specify Requirementsl......................._. _ "" ""' <br /> Disposal Field (Specify Requirements)..................., <br /> ..................................... .............. <br /> ....................................----......._.._... . �. <br /> .............. <br /> (Draw existing and required addition on reverse side) <br /> I hereby,certify that I have prepared this application and.that the work wilt 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 law's of California." <br /> Signed-. . ...... .... ..:._.......... <br /> Owner <br /> By................ ._... _ :...:............ Title........... ..--.............:.................................. ........ <br /> :. <br /> If of er than ownerj <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY. _ ..................................... ..._...._ .......................... ... ...DATE .-r '.�-T.'._ ...... .............. <br /> .._ - _.... <br /> DIVISION OF LAND NUMBE �....� <br /> DST _-.�.. ...:. <br /> DITIONAL COMMENTS...... ... .... .. . . w..._b... _ '. ... . . Lr..........:: <br /> ..................................... :....` <br /> ,1,.,,, ,..al,,.,�.. . ,,.... t� , t. <br /> ..................................... . . o.. .......------------:--.....------.- ................................... <br /> .. <br /> .. <br /> •------.---•--- -----•:---------- <br /> Final lnspeciion b Date._.`--.-, _....._..... ?.... <br /> y:........ ..... --------------- --- ........... <br /> . . ...... .. ......... <br /> t FdS 21677 REV.7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />