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FOR OFFICE USE: FOR OFFICE USE <br /> APPLICATION FOR SANITATION PERMIT yy <br /> -�-----------�-----._...- _..... - �-'--- Permit No..�IJ_�.':2.r-.� <br /> ---� <br /> (Complete in Triplicate) <br /> f '7 <br /> ------------------------------------------------------------ <br /> Date <br /> ....._;1J This Permit Expires 1 .Year From Date Issued <br /> Application is hereby made to-the SanlJoaquin 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. 519 and existing Rules and Regulations: <br /> - 6CENSUS TRACT_----•........ ........ ..... <br /> JOB ADDRESS/LOCATI N....:. <br /> - <br /> Owner's Name. Phone.__.. _-- �` <br /> . �i <br /> Zop _ 9- a <br /> Address / w - `> - tY <br /> License # s'1-.��. .3._--- Phone. G?_Y1__�_ 6_... ------. <br /> Contractor's Name. .__ .._._ t ' -- --`- .. <br /> Installation will serve: t Residence g. Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> /Motel ❑ Other-... -,-------- -----• -------------- <br /> 41O l :. <br /> ' Number of living units:..._ yooms.. Garbage Grinder- / P�-Lot Size-------- <br /> - �� - <br /> } <br /> Water Supply: Public System and name.:. .... � ................Private <br /> Number of bE r <br /> i 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 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 /> i r <br /> PACKAGE TREATMENT ( } SEPTIC TANK 'Size ....... -------- ----- -- -- --------- ----------Liquid Depth..-...:Z------- <br /> -. ----- <br /> N• Capacity... -----TYPe�L67kffiaterial.-.. Compartments_.--.-:-- .---.....- --- <br /> Distance to nearest. Well._---------- '------------------------Foundation___ _---i o... ........Prop. Line........ .- ------- ----- <br /> 4. <br /> I LEACHING LINE (�} No. of Lines E ` Total Length (7C1........................... <br /> a�-------------�- Length of each line..... <br /> -------��- g <br /> 'D' Box_.1......Type Filer Material: _.. Depth Filter Material- -- ---- -- ........ <br /> r <br /> f } /O - Line...... _ <br /> l[ Distance to nearest: Well...... ...--.. Foundation------------------ Property Y <br /> w SEEPAGE PIT [ - wD'epthA 02 Diameter------'a�-----.--'-^Number..........•-�--- --------- <br /> ----------------- <br /> --•- ' •�� Rock Filled Yes [>� No � <br /> i <br /> '.Water Table;Depth " _----------- --Rock Size.*—.-X 1��...---------`---•------.... <br /> ( --Foundation---...__/o- ..._._.....Pro Line.--��............... <br /> • 'Distance to nearest; Well--------------�-�-E7.. --- --�---- p' <br /> t ----1 <br /> G REPAIR/ADDITION (Prev. Sanitation Permit#------------------------ ° ...-----.Pate.....------• --.--.----_... <br /> I Septic Tank (Specify Requirements)_ ......- -------- -------------...........---------------------------------------------------- <br /> ''`....._.... . <br /> ......... <br /> Disposal Field (Specify Requirements)!,.-._----_----- - - ------ ------------------------ <br /> +` .............------------------- <br /> .-------------------------------------- <br /> [_-------------------------------------- <br /> x <br /> F - ....................-------- <br /> __. .__..._...___..-...._.---._.... <br /> j (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: i <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 laws 'of'California." <br /> Signed....... ........ .... ..r --- ---- .......---- _ - -.-....Own <br /> e:r <br /> Title : <br /> . . . --... -- ,--- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> j APPLICATION ACCEPTED BY----- t DATE <br /> DIVISION OF LAND NUMBER... ' ......DATE. <br /> ADDITIONAL COMMENTS - i - sum sem'..4)�/<--�.--3;'HT1.. ....... �4 ..2 =<_... ..... .. ..... .... <br /> ._... . _ <br /> -------•---------------------------------- -------- -- - <br /> ... . -------- <br /> ... ... ....... ----------- .. ... . --.... <br /> f . <br /> Final Inspection b �- Qate.-- F&s 21677 Rev 7/76�3_.. ..- n <br /> r <br /> I EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />