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FOR OFFICE USE: FOR OFFICE USE: [ <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------ ------------ ------- --- ---- <br /> (Complete in Triplicate) Permit No..��-_�.Q <br /> --------------------------------------------------------- - <br /> Date Issued_f�3-_.;�'-; <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 Ordinance No. 549 and existing Rules and Regulations: ) <br /> l <br /> JOB ADDRESS/LOCATI N /- ....... ----------------------------------------------------CENSUS TRACT. <br /> 4K�� ---- <br /> 1 <br /> Owners Name ------------- -- ------ -------- ----- ------- . _ ------- r Phone ��c ��_ ' `�_J'� <br /> :. - <br /> Address-----.... - "` ------- Cit zip p , <br /> Y ------- --- -----_ p--- <br /> Contrac_tor's Name-------.. 1__� ' ------- -._f ----------------------- <br /> ---License #-?a- r------Phone_ -----------' -� <br /> 4,. <br /> Installation:will serve: Residence []f Apartment House.❑ Commercial ❑ Trailer Court. ❑ <br /> .!. . .. ,3 t. _-4.- 4 Motel : Other--------------- ---=----------= ------ '.. <br /> Number of.living units:_- __ ______Number of_bedrooms_ :.___Garbage Grinder------ Size -.---.--------- ------- ------------------ <br /> j <br /> Water Supply: Public System and name .------------- ----'.. i.:.----- _---------.------------------------Private [� , <br /> f <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat E] Sandy Loam El Clay Loam EE•-- <br /> Hardpan El : 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 [ SEPTIC TANK�.. = � Size_ <br /> ze_. = P <br /> ` --6�__� - -- <br /> Liquid Depth _._� <br /> Capacity--/ gV� -- TYPe OCom artments- 37�___ --------------- <br /> Distance <br /> ------- - <br /> ,.. Distance to.n'earest: Well-:-.--- -----------------------Foundation---- ---------------Prop, Line.---- <br /> ---- <br /> ( � �.w �. a <br /> LEACHING LINE [ �}+---No. of Lines-k .--_ ----------- ------Length of each fine-._ d..- ---- Total Length- <br /> • � <br /> i <br /> -------------------------------- <br /> 'D <br /> � ----------------- -I <br /> -- <br /> DFilter Material - - -- - -P ---_--'--- <br /> . <br /> ea� W __________ _-------------- u BattonDistance to rire7 _-_ - __.Property Line-------- <br /> l <br /> -all <br /> SEEPAGE PIT [ De th Diameter`s Number..___ Rock Filled', Yes No <br /> im, - ..s�f-- r <br /> f <br /> Water Table°Depth.------- ---- -------------------- ----.Rock Size-.-- 'k'f // <br /> . Distance`to nearest: Well_-.._-------- ----------------------- -----Foundation___ ------------ <br /> --___- Prop. Line_-.67_____-------.. ._._' _� <br /> REPAIR/ADDITION[Prev'Sa tion-Per #- _ --"'-------------------------Date-----=--------------------------------------- <br /> Septic <br /> ------------------=------------ -----Septic Tank (Specify Requiirrern s)-- _•_; _ �. -------- --------------------------------- <br /> Disposal Field,(Specify_RequJ.re+rl6 s)" ? ------------- ---- ------- - -- - <br /> -, <br /> . <br /> ---------- -------- ---- ----- <br /> -.� 1 , <br /> ----- -- - -- ----- <br /> ----------- -- -------- <br /> -- <br /> -------------------------------- t--- -----_ ---- - °T"'____ ------I------ -- y <br /> j {Draw existing csnd leguired�addition on reverse Side <br /> I hereby certify that I have prepared this application and that-thetwork-will-be done yin accordance with -San Joaquin Coun <br /> ti q � <br /> Ordinances, State Laws, andr`Rules and Regulations of the San Joaquin Local Health D strict. Home owner or licensed agents <br /> signature certifies the following: ` T rY V ► <br /> "I certify that in 'the-performance of;the work for which t}iis�,permit is, issued, I shall not eniploy'any person in such manner as <br /> to become :subject to W'' man's Compensdtion-Ic ws of California.'.'.. ' <br /> Signed_ ------ <br /> caner <br /> = ----- ----- 'T�tl Q 'u- .--- ----.. <br /> [If other than:owner) <br /> " { - 'FOR DEPARTMENT USE ONLY. <br /># APPLICATION ACCEPTED BY__. _ '- -' -�' <br /> . . . .. - ------ - - -- -- --------------- DATE f� � 7=7� - -----`---- <br /> DIVISION OF LAND NUMBER .-----------------`-------- ---- = ---------DATE------- ----------------------- <br /> ---- ------ _ <br /> ADDITIONAL COMMENTS------ - - <br /> -- ----------------- --- <br /> --------------------------------- ----------------- ------ <br /> fi i <br /> --------------------------------- ------ - . <br /> -- ---- � --------------- '� � <br /> ------------ <br /> Final <br /> --- ---- <br /> + <br /> Final-Ins ection b Date-------------------___ _ t <br /> EH 13 24 SAN JC QUIN LOCAL,HEALTH DISTRICT rss 21677 REV. 776 Sen <br />