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FOR QFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ,�_ <br /> (Complete in Triplicate) <br /> Permit No._- ________ <br /> --------------------------------------------------------- <br /> Date Issued__ 'a <br /> __________________..._._____-._._______._._____-__ This Permit Expires 1 Year From Date Issued <br /> v <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-4-56--Lt-vt -------f��l-'s- �z�--- - ---13c��-y-�,.---------CENSUS TRACT------------------------._----. <br /> Owner's Nam .--,5_C ..a ��------------------ ------- ------------------------- L ------------Phone_�..�s� 7�i9��------- <br /> Address <br /> ------ <br /> /, <br /> Address---- G a --------------------- Y----7� - ------------ZiP-7 <br /> ---------------------------- -- - Cit n7 G Z------ <br /> Contractor's Name-- - -- .__________________._____________.LicenseV_ _ _ate-._.Phone_c ► <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ _^ <br /> 1 'totel ❑ Other---------------------------------------------- <br /> Number of Living units:___I------ of bedrooms__./______Garbage Grinder____________Lot Size_91d____x -le-D <br /> -------- -- - <br /> Water Supply: Public System and name--------:;5� -+ �C '-----------------------------------------------------------------------------------------------Private l" <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 /> (PlotIan, showing size of lot, location of sy,cAf!m_in relation-tawells, buildings,etc. must be placed on reverse side.) i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PA AGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth_---------------------- <br /> Capacity-.--------------- <br /> ___________________Capacity----------------- ---TYPe-----------------------Material--------------------------No. Compartments------------------------------- - C� <br /> Distance to nearest: Well_______________________________________Foundation--------------------------Prop. Line---------_--_--_____-___� <br /> LEACHING LINE [ ] No. of Lines____________________________Length of each line.______________.___________.Total Length.____________________------------- <br /> � <br /> D' Box-----------Type Filter Material--------------------Depth Filter Material-------------------.--------------------•------•-----------� <br /> Distance to nearest: Well----------------------------Foundation----------------- -----------Property Line----------------------------------- <br /> SEEPAGE PIT [ ] Depth-----------.----Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth---------------------------------------------------------Rock Size--------------------------------------------- t <br /> Distance to nearest"Well__ - : -:-_________ ______ ___________Foundation--------------------_ Prop. Line-_ _______. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____________________.____________-__________-Date-_____-____--_____________________-____) <br /> Septic Tank (Specify Re; uireAihts}-___ -------- ---------------------- ---- 1 - ----. ------- ---=---- ------- <br /> Disposal Field(SpecifRequirem_ents�. , J" z-_,�s ,�. _ .-��--__ f_ <br /> -_,.- _ <br /> -------------------------------------------------------------------------------------------------------------------------------------- <br /> ________________ _________ _- __ ____.---__-- __-_.___._ ______. ____ _ __-__-_-___--___._ -_-- _____---_--. __ _ _____ _____. _. - -_�Y__?. a_ < <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that l have prepared this application and that the work will be done in accordbnce with San Joaquin- Ceunry <br /> Ordinances, State Laws, and Rules and Regulations"R of the San Joaquin Local Health District,-Mame--6wner 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 a <br /> to become ss b[ec to <br /> Work=ns-CompensationJawe of California." <br /> Signed-. 1�` , i_:1'(�L�.�� - ------ -- - ------- -----------Owner <br /> By---------- L:� ' ------------------------------- -y--------------------------------Title—------_--------------------------------------=--------------------------- <br /> (If other than owner) <br /> FORD TMENLUSE ONLY <br /> APPLICATION ACC PTED BY--- �'", _-- - ---- - -« ----DATE --1�--.�----� _. _ <br /> OF LAN NUMBER----------------------------------------------- ---------------------- <br /> DIVISION DATE . <br /> ADDITIONAL COMMENTS_------------------------ ----------------------- <br /> ---- -- -- - ----------------------------------------- <br /> ----------------- <br /> ----- <br /> ---- -- ----- " — --- - --- --------------------------------------------- - -- - : ------ ------------------------ - -- -------- --- <br /> ---- <br /> --------------------------------------- ------ ----------------------------- ----------------- -------------------------------- ----- <br /> - <br /> Final inspection bY.------- ------ ---- -- -------------- '__..--_'.Date — <br /> EH 13 2a SAN JOAQUIN LOCAL HEALTH DISTRICT Fos zie» REV. 7/76 3M <br />