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FOR OFFICE USE: FOR OFFICE USE: <br /> ;i APPLICATION FOR SANITATION PERMIT �'� / <br /> ........... ------------------ ...... <br /> ie (Complete in Triplicate) Permit No,,... ............ <br /> ............. -- ............ .... <br /> ii Date Issued7-V.7 �! <br /> ------------- _. This Permit Expires 1 Year From Date Issued l <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described, i <br /> This application is'made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION------a1- 3 ff - - -_-- � .................----------- <br /> ----- .... <br /> i <br /> ,�A ...._ g . <br /> CENSUS <br /> .. <br /> Owner's Name--Ji- -. ..------------- -- -----------•--------=--....._....:.....-Phone .....----- ...... <br /> j--2--Z _.-:. ,-.....___...Address � f Cit - <br /> .7' <br /> Contractor's Name. OWK-0-4- _u��Oj' `� License # Phone-.? <br /> ......... . .......... <br /> Instal-lation_will slar_ve: Residence [r*' Apartment House ❑ Commercial ❑ Trailer Court ❑ 't <br /> h i <br /> Motel ❑ Other - ------------------..-....---- ----- " <br /> Number of living units;......./......Number of bedrooms...-....Garbage Grinder.I.....----Lot 'Size... - ..._....' <br /> Water Supply: Public System and name,_ . ..._Well- _.......... ............................eve f-- ----------------- -- -- --------------- Private ❑ <br /> Character of soil Oct depth of 3 feet: ..Sand ❑ Silt❑ Clay ❑ Peat ❑ landy Loam] Clay Loam ❑ i <br /> I 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 /> PACKAGE TREATMENT _ _ <br /> [ ] SEPTIC TANK Liquid Depth... <br /> �i Capacity....... ....... -----Type-----------------------Material--"---------- No. Compartments...oZ.-• <br /> Distance to nearest: Well-L------------------ ----------=----------Foundation-------.. . ............ Prop. Line------------------------- <br /> LEACHING <br /> --.------- .------------LEACHING LINE ?( ] No. of Lines - --- - .3.... .---.Length of each line------- Total Length ......12U---.... ..."-.-"-....... <br /> c li 'D' Sox--.- - . ..Type Filter Material----..:. .... ..: Depth Filter aterial...----------------.----------.--------.-------------.... <br /> Distance,to nearest: Well:..-_. .._ Foundation------------------ --------Property Line-..-.--------------._._._------- . <br /> Depth---, ._.._.D+w ----- ---�---` tuber- - --`----. Rock Filled Yes)Q No <br /> Water Table De th.....' 42--- --------------- 1 <br /> Nu rr <br /> P � --- -- - --------------Rock Size... P7`[ .. :.... <br /> 4 ! Distance to nearest: Well--------..ko-- ...................--•Foundation--.16....... Prop. Line------...-.-....--........ <br /> .. <br /> / I (Prev.,Sanitatio'ri Permit# ------.-.-.- . Date --•.. .......... .......... ] a f <br /> Septic Tank {Specif `--=------- , <br /> ADDITION � <br /> y Requirements)--—_;.-... ' .... ] <br /> Disposal field [Specify Requirements)- ...................- { - ' <br /> I�-------•-- ------------------- ------... -• -----------------._"------ .. -----------------•---•- ..... -...-. ............. ---- --- •. ------ <br /> _. <br /> - <br /> ' (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared,this,dpplication and that the work will be .done in accordance with San Joaquin County <br /> Ordinances, Statey Laws, and Rules and. Regulations of the San Joaquin Local,.Health District. Horne owner or licensed agents <br /> signature certlfies�the following: <br /> "I certify ` <br /> that in the <br /> performance of the work for which this permit is issued,'I 4hall"noY employ any person in.such manner as <br /> to becom <br /> Signed. --. subject'�to Wor an's Compensation laws of California." v <br /> � a,,_._._ <br /> (� .. — <br /> BY.... ............................................................... ..................... .... . Title........ <br /> I [If other than owner) <br /> �i F R D PARTME E ONLY <br /> DIVISION P LA ACCEPTED BY--------- - DATE ... ............. <br /> APP <br /> APPLICATION <br /> CD NUMBER. - '� ..... DATE..... . ------- ----- - ---------------- <br /> N <br /> ADDITIONAL COMMENTS... ........... l " .................... ---- "" ................. - - ---- <br /> ! <br /> Il -- --------- ----------------- ----- ------- - --•--- -- - ------ . <br /> - <br /> '.'.R -----------•------------ <br /> Final Inspection 6 <br /> :...............Date.... . <br /> 21677 REV. 7/76 3M <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F s S <br />