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FOR OFFICE USE: ' <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> �7' <br /> " ---------- ---- <br /> ------------'-'------------------------------------------- {Complete in Triplicate} Permit No.. <br /> 7 . <br /> -------------------------------------------- <br /> __"___""__" This Permit Expires 1 Year From Date Issued ;Date Issued-/-7A- -'__-- <br /> -------------------------- -----------------_" _--"----"_." aquin Local Health District for a permit to construct and install the work herein described, <br /> Application is hereby made to the San Jo , <br /> This application is made in compliance with C�oun/ty^Ordinance No. 549 and existing Rules and Regulations: i <br /> TRACT-------- -- -- -- <br /> , <br /> J" CENSUS -- -- <br /> JOB ADDRESS/LOCATION- Phone-------------------------------- <br /> Owner's Name..- --�/.t-..�--- --------- <br /> ,- ------ .�--- - = -------- ----- ---- ---- -- --- <br /> ---- y <br /> t I --------- City ---------- ----- <br /> --------- <br /> ---------------- <br /> Address-----=-------------------- ---- -:-- e� Zip <br /> Q� <br /> s = <br /> ----.License #_, ._ T Phone.__ <br /> l m <br /> Contractors Ncime_&E- --; <br /> nce artment House ❑ Commercial ❑ ~Trailer Court ❑ <br /> Installation Twill: serve.. R side +P <br /> f `> Mote! ❑ ---Other------- --------------- <br /> Number of.Iiv.ing.unjits: Number of bedrooms,_----Garbage Grinder.-=.---------Lot Size----..- -.--- <br /> ------------------------------ ------- ---------------------------- -- rl <br /> - P <br /> Water Supply: Public System'and-name <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt El :Clay ❑ Peat ❑ Sandy Loam El Loam Elf <br /> - .. ' _. , 1. " Hardpan ❑ Ad ❑ <br /> obe Fill Materia`l___- ------If Yes, type -------- -- ----------- <br /> I <br /> � l <br /> (plot plan, showi`g,Fsize of lot, location of system in relation to wells, buildings-etc. must be placed on reverse side.] <br /> 1 . <br /> NEW INSTALLATION: ]No septic taI k or seepage pit permuted if public sewer is <br /> available within 2Oi7 feet,} <br /> PACKAGE TREATMENT p] . <br /> SEPTIC TANK [ ] Size_ Liquid Depth'-------- ------- <br /> -Material ---No. Compartments------ '-- <br /> ; <br /> � . ] Capacity - --- e-�--------- ------ t i <br /> Arn ------------ <br /> Distance to nearest.: Wel.l._"___-"._""--==--_--'------= Foundation_."� ----- ----- ---Prop. L.i <br /> Total Length e <br /> LEACHING LINE. I]� No..of Lines '; - ------- Length of each 1-ine..--.-:------'-- .------ - 9 .. _: - _ <br /> 'D' Box__ ------.---Type F;Iter Moterial_-,- Depth Filter Material:_ D--��-•.- a; <br /> Y <br /> ----- <br /> Distance to nearest: Well_ __" -----Foundation_-";"-- -----------------;----Property Line <br /> _ .. k ❑ <br /> -------------- <br /> Rock <br /> � R Filled .Yes No ., <br /> i INumber­' f fir. , <br /> SEEPAGE PIT [ :]^ ! P ----------- <br /> -------------------- <br /> p <br /> w <br /> Depth -- Diameter---- -�---- --- ---- -� ""Rock Size. <br /> -- -------- ---°--- ------1,�.----- . <br /> Water,Table Depth -- --- - - - i = <br /> - - <br /> -Foundation- ---- -- -------- Prop. L'ne <br /> Distance;to nearest:Well-------- -". �-` <br /> -- ... - <br />[ f Date_.- <br /> REPAIR/ADDITION (Prev:Sanitation Permit#"_----------------------------- <br /> i <br /> --------- ---- --- - <br /> - <br /> Septic Tank.(Specify Requirements)---,---------°°-------- + <br /> _. E ��-a � - -�---¢ ------------- <br /> Disposal Field {Specify Requirements]_. <br /> --- ------------- ------- <br /> -------------- <br /> ---- <br /> E <br /> # -------- <br /> ; - - -------- <br /> ------- ------------------------- <br /> - <br /> i i {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 /> San Joaquin Local Health District. Home owner or licensed agents <br /> Ordinances, State eaws,-and- Rules and Regulations of the <br /> signature certifies the following: - kerson in such manner as <br /> "I iertify'that in the performani l Lthe work for which this permit is issued, I shall not employ any p # <br /> to become subject 'to Workman's ,Compensation laws .of California." <br /> Signed -- <br /> =- ,j - --- <br /> !� -- <br /> - - .- -= - -- <br /> Title <br /> { f{I'f'o#her'thari owrier] c ` <br /> [ FOR DEPARTMENT U E ONLY ; <br /> " ------- DATE "^7-APPLICATION ACCEPTED BY-----" -- - -------- _- -- <br /> --_ <br /> -. ------ -=- -DATE-------- ------ --- --- ------ - - <br /> DIVISION OF LAND NUMBER; ------------ --- <br /> -------- <br /> ---------------------------------------------- <br /> ----------- <br /> ---=------ ---- <br /> ----`- - ------------------------ <br /> ------------------------ -------------------------- ------ ------- <br /> ADDITIONAL COMMENTS --------------- -- --------- <br /> L `------------ --------=---- ---------------------.-- : ---- .......... <br /> ----------- - ------- ------- <br /> -- - ------ . . .. <br /> t ---------------------- •----------- . - ------- ------- <br /> --------------- _ <br /> ------ ----- ------- <br /> ------------------------------------------ Date <br /> _ _. _ ------ -------------- <br /> - <br /> Final Inspection by:-' -- --•-- j. <br /> - "'---f --"" 11F&5 21677 REV. 7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />