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;A,- <br /> FOR OFFI.CEUSE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------- --------- <br /> (Compin Triplicate} Permit No..� ..-`�-:�`� <br /> ----- ----------------------- � `� ?.� <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION...[17.49.49-----4v--- - - ------------------------------------------CENSUS TRACT <br /> Owner's Name--------- fJ�` v.`'N .a.N------------------------------------------------------------------- -------- ---------------------Phone--------------- ---------------------- <br /> Address---- - --ICS- --- ---- --- City---7"?40C� --- -----------------------Zip ---- <br /> Contractor'sJ*4/00&— `Otf------ W_ic---License ------- <br /> Installation will serve: Residence ;K Apartment House E] Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------------- ---------------- <br /> Number of living units:------I--------Number of bedrooms----.7-----Garbage Grinder-----.------Lot Size rs" •7� i�' E�cG1� <br /> Water Supply: Public System and name------------------------------------------------------------------------------------- ------------- --- --------------------------Private (� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,j lt� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK X Size---/.-Zo4------4L1?L,_--------------- ------Liquid Depth---57W�­ ........... .... <br /> Capocity_/Zva------Type--- -------------------Material------------------------:-No. Compartments--------- 2—----------------- <br /> Distance to nearest: Well__.1PO *------------------------Foundation--_---1.0-__`__---------Prop. Line__._--_-..._---.----. <br /> LEACHING LINE No. of Lines.--------?----------------Length of each line-----------?-G'-----------Total Length------ Q------_--------,_ <br /> 'D' Box__--:1------Type Filter Material------/?474A-.Depth Filter Material.----1 t9--,-*----------------------------------------------- <br /> Distance to nearest: Well------ ----------Foundation-------- ----------------Property Line-------�-_ '---------.-----.---. <br /> --SEEPAGE:PIT [ ] Depth__---------------Diameter---------_-----_---Number-------------------------------- Rork Filled Yes [] No ❑ <br /> s <br /> Water Table Depth---------------------------------------------------------Rock Size---:- - - ----- '�----------------------- <br /> Distance to nearest: Well----. -- __'.-----_-. --------Foundation.------- -.--------.-.Prop. Line----- ---- ------------- ' <br /> REPAIR/ADDITION (Prev. Sanitation Permit# ---.----_ _-.Date_-=-----------------------------------------} <br /> Septic Tank (Specify Requirements)-----� 04--- �--- -------------------------------- <br /> -.0. � _ <br /> Disposal Field (Specify Requirements). 9�-- x^ �f � � ' f- <br /> --------------------------------------------------------------------------------------------------=-------------------------------------------------------------------------------------------------------------- <br /> ---- - - - - - - <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 beco subc�to ork ompensation laws of California." <br /> Signe - - a .----------Owner <br /> By--------------------------------- -------------------=------ -- ----------------------- -----------------Title --- --- ------- <br /> -------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- -- -------- ----- - ----------------- -- <br /> ----- --------------------------------------------DATE -- --��lS. ------- - -- <br /> DIVISION OF LAND NUMBER------------------------- -- DATE.----_---- <br /> ADDITIONAL COMMENTS----------- ----------------------------------------------------------------------------------------------------------------- --------- <br /> --------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> = --- - --------------------------------------- ----- <br /> Final Inspection by--------------------- ------ ----------- ------- -- ------ ---- ---- -- - -------------------Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />