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FOR OFFICE USE: T FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- �------------------------- - (Complete in Triplicate) Permit No. �--- - --- <br /> ----------- - ------------- � <br /> Date Issued.- L11 <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 constt.u& and-installtthe',work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> or <br /> JOB ADDRESS, O --.�.,N,. - <br /> - -------- -- --- A <br /> ,. , --._._CENSUS TRA <br /> C <br /> T-`----------�------ ------------Phone--- ------------------------------ <br /> owner's <br /> 7p.� <br /> Name:.__. _ : : : <br /> City-- - __ 'Address----- ---- --- Phone <br /> n ----------License # lCotractor's Name-__ <br /> Installationwill t, <br /> ` <br /> f <br /> serve ' Residence Apartment House ❑ ;Commercial ❑ Trailer Court ❑ S' <br /> k <br /> - � . � .t......• Y otel ❑ . Other------- -'-------"_---:-- ---__----_'- � F <br /> Number of.living units:---.-�--_____Number of.bedrooms_.___..__Garbage Grinder_"------.___Lot Size-__- - ___.___. ___ --` <br /> Water Supply: Public System Wand name . :- . .. --: _-.------------------------ --------------=--- ----------------- --- ------------------------ Private <br /> Character of soil to a depth of 3 feet: ?'. Sand [] 'Silt❑ 'Claylp Peat ❑ Sandy Loam ❑ Clay Loam <br /> -Hardpan ❑ Adobe'-7 Fill Material-----------.If yes, type-------_______________._____--_ <br /> buildin s :etc.:must be laced on reverse side.) <br /> (Plot plan, showing size of lot, location of system 1n relation to-wells, g ,. P <br /> NEW INSTALLATION:"` ;(No septic tank 'or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK- [11 "` Size_=��_X --O X-:_/--=----- -------------------Liquid Depth._(v___--------______:.�_-- <br /> Q <br /> ! . . , <br /> No. C <br /> omp rtments :_Ea acitY; ► ----------- <br /> 77 <br /> -- ----------------------- <br /> arest: WeI1Distance,to neuyf0 <br /> No. of : - - - <br /> ---- <br /> . Len th of each line.--� TotaLer <br /> LEACHING LINE <br /> D Box '_.Type Filter Material__- _ _____.Depth Filter Material_- - ___ _ '__-_____ :_ _ <br /> ._ - <br /> oundation�,_- P I y --------------- <br /> 0 <br /> ------ <br /> n... _.,st,,Wefl---- � � Pro ert Line ? <br /> SEEPAGE PIT [ ] .1 p �i.- D t" -. .. - ._: <br /> Disfanca to ne`are <br /> De ih.' Diameter Rock Filled Yes, "No ❑ <br /> e 1 <br /> Water Table Depth -1 <br /> Number___. <br /> -------; Rock Size, __ <br /> �. <br /> Distance to nearest: Well--=------------ ------.Foundation--------- Prop. Line-------- <br /> ---_ -- <br /> __........... <br /> _ = _ _ ;Date - <br /> REPAIR/ADDITION (Prey;Sanitation Permit#_:_______________________ ________. <br /> Septic Tank (Specify Requirements) �. — . ------ -- w :------ --------------- ---------- <br /> Disposal Field I-Specify Requirements)- -�---------- - £ --------- ---- <br /> r" �_---------- ------- - ------------------ <br /> _ - -._�- = <br /> • - '_----------.___-__________ __-.---______-- +___,__ --____.___ _. _ -___ __ ________------_-_______-__.___--________- <br /> jDrawexisting and required addition on reverse side}.. i <br /> I hereby certify that j have•prepared this application and that the work will be done in•racftor d nye IM <br /> with San Joaquin County <br /> Ordinances, State Laws, grid Rules and Regulations of the- San Joaquin Local Health District;`Home owner or licensed agents <br /> signature certifies the following: k ; <br /> .. ( _ <br /> I certify that id-the performance of fol-which this permit is issued, :I shall riot employ,any person in such manner as <br /> i <br /> to become. subject t Workman's Compensation .laws of California.' '** ` <br /> Signed --- --- . .--- - Owner <br /> ------- <br /> BY-°---------------- --- Title _; <br /> `I. o . . than:owner) <br /> ;Z FOR DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY # - DATE - <br /> -- ----- --------------------- - <br /> DIVISION OF LAND NUMBER---------- yl -----------= ------=------:---------------- =------'- --------DATE.-- ---- -----.----- ----- --------- ---- <br /> I <br /> ADDITIONAL COMMENTS _.. :._ =------:-------- ------------------ ------------------- ------------- - - I <br /> ------------ <br /> ------ ------------------------------------------ ---•- ---- ------- -------------------------------- <br /> - <br /> s - -- <br /> ------ --- <br /> /` j <br /> Final•Inspection•by..=_.. X_._ ate - �/� 7 ----- ------ ----- <br /> EH 13 24 SAN J A I AL H ALTH DI TRICT F&5 21677 REV. 7/76 3M <br /> ., - <br />