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FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ ............- ?�i-SzZ <br /> ---. - (Complete in Triplicate) Permit Na................ ...... <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. . .---- ----.--•--••--.-..._ <br /> ----- -•--CENSUS TRACT------------------ -- <br /> .e172 <br /> .......... <br /> Owner's Name................. ------- ,Phone -��f-.�9`�'�y <br /> Address.-- 7s - CL+.GIJ � ./.:e�� Ciry.. _ Zip_..: f <br /> sa <br /> Contractor's Name......... License #.- - Z�---.-Phone.. 6 ._!;. �------ <br /> C'x <br /> Installation will serve. Residence ❑ Apartment House ❑ Commercial.9 railer Court ❑ <br /> Motel ❑ Other------- --------------------------- ------- <br /> Number <br /> ---Number of living units: -- -_----.__Number of bedrooms............Garbage Grinder_---------Lot Size._ �.-.:---.._..... ..... ._ <br /> Water Supply: Public System and name................ .. -----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �1 <br /> PACKAGE TREATMENT [ } SEPTIC TANK [&r- ' Size _2.y ----------- ............Liquid Depth...4/................... <br /> AO ...........-No. Compartments-.........Z-"----. _. -- <br /> Capacity.. 74.0 ......Type <br /> . Distance to nearest. Well....�d� N.................. .........Foundation...,] . ..___..--....Prop. Line...._...._- .--...-- ._... <br /> LEACHING LINE No. of Lines ._.. .------------_- Length of each line-----Z4_ --------------Total Length ...... ----------- ._ <br /> , <br /> 'D' Box------......Type Filter Material.ar_ __!C..yyam� Depth Filter Material------./Jr------------------------- ---------------------- <br /> Distance to nearest: Well--fo_)._..___ --Foundation----1&!--------------Property Line_..��.._`. -------------- <br /> SEEPAGE PIT [or Depth... 7- '....Diameter..,.33__'. -------Number..... -------------------------- 1/ 00, Rock Filled Yes ®' No <br /> Water Table Depth--------/-Oz�--------- .... -- ------------------Rock Size._.p?. -... ............. <br /> ...- . -- <br /> Distance to nearest: Well---- ...............Foundation------ Q..-....--.--.Prop. Line .. .-.-__-- .__--- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................___..............._- .......Date._...__...------------------------------------) <br /> Septic Tank (Specify Requirements]------ ----------- <br /> Disposal Field (Specify Requirements)------------------------ ---..---.----------- <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, t shall not employ any person in such manner as <br /> to become subject or man mpen ation laws of California." <br /> Signed---------- --- ----- -_.. .. .... .. Owner <br /> By.................................................. �. - �Title. <br /> ----------- <br /> (If other thanowner) <br /> POP DEPA NT Ll ONLY <br /> APPLICATION ACCEPTED BY........ . . .. - ------•---------- ------DATE ..... �' -�$ 7--- <br /> DIVISION OF LAND NUMBER..----- ----------- •• --- -.... •--- DATE..........--- - - - ------------ <br /> ADDITIONALCOMMENTS-----•--------------- ---------------------------------------------------- ----------••-•----- ......................... ....................... ......... ...... <br /> ---------------------------------------------------- ---- -- -- --------------------------------------------........---------------------------------------- ----------­­ ....... ... <br /> ---------------•--- ,:...r<---- - ----• ... . <br /> --------•- ........ <br /> Final Inspection b - ----- ------ixr--. f,M�� � i' [. r ...Date.. _ . E_.� <br /> EH 13 24 SAN JOAQUIN L CAL H T Q T IC�� 4 &5 21677 RFV. 7/76 3M <br />