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L, <br /> 2c� <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ ------------------ - <br /> Permit <br /> (Complete in Triplicate) <br /> ----------------------------I------ ---- --------- ----- <br /> Date Issued-.3'-,�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 oconstructilao install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules andlRegulations: <br /> JOB ADDRESS/LOCATION--- 4._E- A&,/ '7----------------------------- --- ------ -- CENSUS TRACT---Zf' . <br /> --`-'�, __Cj-*---- ........ <br /> � <br /> Owner's Name---ioT-W'------�C -1 -�1 -- - ----- ----------------------------------- --- ---------- ------------Phone = - --3. <br /> Address---- .------------------------------------------- -- ----------------------------- city r zip----{w <br /> Ile <br /> Contractor's Name--- - -► off -,+ ------------------------License #- 4- 1 ----------Phone---, � , -- - ----- <br /> Ar <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------- ---- ----- -- ---- ---- -- _ } <br /> lt <br /> Number of living units:______.__,.__----Number of b6drooms -- ._Garbag Grinder-. Lot Size------��-�' ---.------ --------------'-\ <br /> Water Supply: Public System and name - 1 -------- ---------------------- `- Private <br /> i � <br /> Character of soil to a depth of 3 feet: Sane! �] Silt❑ Clay ❑ at. Sandy Loam [.�- ay Loam ❑ <br /> Hardpan ❑ Adobe Q;; Fill Material-- yes, type ----- ----- -------- --- ----- <br /> (Plot plan, showing size of lot, location of system in relation��tto,o�fy!welsl's a iIdings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepal e,pit pir�mitTd-if pullic sewer is available within�10Wfeet, <br /> .� . <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [7 ize___--- ' ---------------------------------- Liquid Depth-r-------------------------T, <br /> Capacity-- --" ---TYPe-----------------------Material- --------------No. Co parNshts----- ------- <br /> Distance to nearest: WeIL.__�-._- ___ ________ ________Foundation--------------- ---------Prop,Line-1 <br /> LEACHING LINE [ ] No. of Lines----------------- LengthLo each line------------------------------Tota Length..-.- '�---- ------_--------_-------- <br /> 'D' Box------------Type Filter Material------- -------Depth Filter Material---------i--------------------------- ------------------------ <br /> Distance to nearest: Well ______---- Foundation-----------------------_---.Property Line-------------------------------------- <br /> SEEPAGE PIT [ ] Depth-----------------Diameter- -_---_---.-.---N;umber ---___--_________________ Rock Filled Yes ❑ No <br /> ,or / 1� ,f. ��t.r <br /> Water Table Depth-- ---- --- --------------------------''_ Rock Size------------------------------------------------ <br /> t"R <br /> Distance fo{nea est: Well. -- --- :,-- -------------------�Fo`dation--------------------------Prop. Line--------------------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-- ----- ----------_ .! ----_---------------Date, _____________._________.______) <br /> Septic Tank (Specify Requirements)---- -------------------- -------------------- -------------------------------- <br /> Disposal Field (Specify Requirements)-..-30/---- `���� % t .- ,/r1t 5'- - 1���- iCC ------------ <br /> ----------- -' � ' - - '--'� <br /> - -------- - ---------------- ------------------------------------- <br /> ------------------ ------------------------------------- <br /> (Draw existing and required addition on reverse sicleii <br /> I hereby certify that I have prepared this application and that the work will be donerin. accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heeiffh+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 Workman's Compensation laws of California." <br /> Signed---- - --- ----------------------------------------------------Owner/� <br /> BY--------- " ------------------ -- --- --- - ------------ ---- -------Title- It {/, = -.- <br /> (If other than owner) <br /> 09n A FO EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------- ------------------------ ------------ ----- -----------------DATE.--- ."' <br /> DIVISION OF LAND NUMBER-------------------------------------------------------- - ----- --------------- --- DATE------------------- - <br /> ADDITIONALCOMMENTS---------------------------------------------------------------------------------- ---------------------- ------------- ----------------- ------------------------------ <br /> ------------------------- ----------------------------- ------------- ---------------------------------------------------------- ------------------------------ ------------------------------- ----------------- <br /> ------------------- ------------------------------------- <br /> --------------------- <br /> Final Inspection b -----------------------------Date -- ..---�� <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV- 7/76 3M <br />