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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION-FOR-SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.7...�.. 3� <br /> Date Issued.......'.......-'.. <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 construct and install the work herein described. <br /> This application is made in compliance with County OrdinanceNo. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. z......t -----"`- '� CEN5US 7RACT <br /> ... .... .....L aI ���"` <br /> ........•-- --.....--- <br /> Owner's Name...'" C<'e�"" Phone <br /> / •- •----- -- ----------- <br /> Address-----�. .- -e(. .. - .....: �.. City......... Zip..,'... <br /> y <br /> Contractor's Name.......- <br /> ..... .............. ........ .........License #- .. .. .. ._..... .....Phone.... -..-............. ....... <br /> .... <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other--•............... ...... . - -------- <br /> Number of living units:....--- ---Number of bedrooms......�.-GarbageGrinder__ ...Lot Size.........�..'�__........- ........................ .... <br /> Water Supply: Public System and name--------- - - ------------------------............ ------. -------....... .......... --------- ------Private ( C <br /> Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Locrm E?N <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,] 1 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size:.._..A ' <br /> ...1?.....� /.',.... . ....... .. .........Liquid <br /> Vi✓ - t' Depth------ <br /> No. <br /> __ <br /> No. Compartments 09Capacity.. _...Type---- -- -------- -----Material - - - --- - <br /> Distance to nearest: Well. .........--------..... . Foundation. .._ .._.. . .. . ....Pro. Lin . .....� <br /> LEACHING LINE [ ] No. of Lines.....' - <br /> ................Length of each line -- - - .. Total Length....---------------------...-......-- -- <br /> D' <br /> Box---- .......:Type Filter Material.. ... - . Depth Filter Material. ..�.. <br /> _ of <br /> t l cv <br /> Distanca to nearest. Well-.. ----------Foundation. .�IsmProperty Line.............................. <br /> SEEPAGEPT Depth. ------_--------Number.......... <br /> - ------------- Rock Filled Yes (b'` No E]Water Table Depth.....--- - ------ ------- ......................Rock Size........'�f - -----.... <br /> Distance to nearest: Well.. j.......... Prop. Line_._...---._............ <br /> -<__-..Foundation._ +'? <br /> REPAIR/ADDITION [Prev. Sanitation Permit#... ................ ........ .....Date......................................-------_] <br /> Septic Tank (Specify Requirements)--- ..... --- -•--- -••---------------•--------k--- ................... ....... ......... ------- ._..-.. ....... <br /> Disposal Field (Specify Requirements) ----------------------------------------------=------- -- - <br /> f <br /> --------------- ....---•--. ----- ................-.... = .................................................... ---------...------ ....._ <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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: <br /> "1 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 �+ <br /> .. ..�..-_ . <br /> .................... - -.Title---- <br /> ----------------------------------- ------ <br /> ---Owner <br /> BY <br /> (If other than owner) <br /> FOR PAT ENT USE ONLY <br /> APPLICATION ACCEPTED BY............... . � <br /> -----------------------------I.....DATE � ,`' � �-� ---...-------- � .. <br /> DIVISION OF LAND NUMBER DATE.. --. ..--- --- -- ........ ............... <br /> ----------------------•------------------ ------------------ <br /> ADDITIONAL COMMENTS. ............ ............--- ----- ---------------------..... <br /> ------------------------------------------ ------.... .. .......-----•--------------------------------------.... ------•----------I-----------------•------- ---------------- ...... <br /> ------------------------ ---------- ---- -------- - --- ----- ---- •-------------- ---------------- ---------------------------- ---------------------------------------------------- <br /> Final Inspection b Date- _... <br /> Y •--..... ------ -------------------------- -- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F3S 21677 REV. 7/76 3M l <br />