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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No7 --.y-g. <br /> ------••-•- ---•---•----- .-- ----------- ---- This Permit Expires 1 Year From Date Issued Date <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.--4.4.;T.... ----... T !l7.A-ALT -e•A CENSUS TRACT. •- - -- ..-... <br /> Owner's Name.. AJ A-M/ ----------- -- ------------- -- ..... ----------...--------------.-------..-.--Phone. ...... <br /> _ - . ... . CA ._.-_...Address----- ------- - �.L.S', o53,-., ,.... .--.A .A-�LT� . Zip- . <br /> ...Contractor's Name.-. ,- A ......Phone._�e�G•d- <br /> Installation will serve; Residence [Apartment Mouse ❑ Commercial ❑ Trailer Court [� <br /> Motel ❑ Other- - ----- - --------------------- <br /> Number of,living units:.--..-/-------Number of bedrooms----P;�..Garbage Grinder---.------.-Lot Size--------------- - . -..-.---------:---..-___-- <br /> Water Supply: Public System and name.. ....------------------- ---------_ _--------Private IM <br /> Character of soil to a depth of 3 feet: Sand Silt D Clay-O Peat ❑ Sandy Loam ❑ Clay Loam ❑ <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.) S <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ) Size _ _- ---- - ---------- ------------------------------Liquid Depth.......................... <br /> Capacity---------------------Type - - ----.-.. .--...Material------------------------._No. Compartments------------------------------- <br /> Distance to nearest: Well--------------------- ------ ---- ---------Foundation--------- . .--...... Prop. Line-.----------.-. ........... <br /> . <br /> LEACHING LINE [ J No. of Lines ...-----..Length of each line------------------------------Total Length .. -----------------.__-.............. <br /> 'D' Box....-.......Type Filter Material.--. -.. `---. ---.Depth Filter Material-- ---------------- --------------------...---------- .-------- <br /> Distanceto nearest: Well___-------:__, ..-,w--- Foundation-------------_-_--------.-Property Line--------------.-------.-.-.-------- <br /> SEEPAGE PIT [ ] Depth....------------Diameter---------^.........Number-._--------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth-------------------- ------- '--------.Rock Size-...... <br /> Distance to nearest: Well--------------------------------------- ----Foundation---------------. .. ...-. Prop. Line.----.-.----------. ------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------ -------------- _.............Date------------•-m•-....:---........-....-.---.--1 <br /> WiSe tic Tank (Specify a uirementsl. . /"p ' <br /> ------ <br /> Disposal <br /> Field [Specify Requirements)-- �QR- k-_, J�r1[-. <br /> ------------ ----------------- •------;-------- --------- - --------------------------------- ........................I-------------------------.--- --------------- - -----------.--- -- - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I 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 /> "I 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 orkman's Compensation laws of California." <br /> Signed--- , ._f -,...... �Jl/ .� -- --------- --------- ------Owner <br /> �%�By------- C�... ...:----- y... .--... Title--- <br /> (If <br /> itle--(If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ...DATE ...- �_ ."-7_ .... <br /> DIVISION OF LAND NUMBER.............. . DATE...- <br /> ADDITIONAL COMMENTS- ------------- ------ - ................ <br /> -._--...------------------------ --------- -------- -- -- ---------- <br /> Final Inspei_tion by;... ......... . - <br /> Date - � ....... . ..... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />