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FOR OFFICE USE: OR OFFICE USE <br /> APPLICATION FOR SANITATION PERMIT Permit <br /> ----------------------- . <br /> 1 {Complete 1n Triplicate} ----- <br /> 4 <br /> Date Issued-.S 7---7. <br /> ....................----..........-.....................- I 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.. � 1-_:3 �h�i��� CENSUS TRACT.. ------- <br /> ------------- . <br /> 7 <br /> Owner's Name. - / - - `a <br /> - - --- ---------- <br /> Addressf r31. City. -- ----------------Zip = <br /> Contractor's Name--..-. ..." (�` -------------License # 3�. 1..-...Phone6 r <br /> Installation will serve: Residence ,Apartment House E] Commercial ❑ Trailer Court El <br /> Motel Other----_---------_-- -.--- fr <br /> Number of living units:..._/...--Number of bedrooms..- ....Garbage Grinder--_---------Lot Size--�.-.�..�--................. . <br /> Water Supply: Public System and named--------------- ----_----- ------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 /> ---------• <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------- --------- -----------------------------------------Liquid''Depth--------------------..- <br /> Capacity... <br /> --------.Type•........................Material-- --- -------__-_-;_:-No._Compartments------=----------------- ------- <br /> Distance to nearest: Well-------------------------------------------Foundation---------- - -.-_.. ......Prop. Line------.--------...---..--- ) <br /> LEACHING LINE [ ] No, of Lines....:t ----------------------Length of each line..----. ......Total Length .. ........................ <br /> D' Box.._....... r <br /> --�` iTYPe Filter Material----:...............Depth,Filter Material.......-- .............................- ---..-.----.......-.-. <br /> Distance to nearest: Well------------- --------.........Property Line._----------..-...... ------- <br /> SEEPAGE <br /> E <br /> SEEPAGE PIT [ ] Depth....---- Diameter--------------------Number----_--------------------------- Rock Filled Yes ❑ No <br /> l _�_- _ , <br /> Water Table Depth------------------------------------ --- ------------Rock Size------- ............................ <br /> Distance to nearest: Well_------.•----;--.--_.. --------------- Foundation---.-----------...........Prop, Line-----_----------- ----- <br /> t. <br /> REPAIR/ADDITION.(Prev. Sanitation-Permit#---------------- <br /> Date.-. ---• ------------------------------ <br /> Septic <br /> ----------------- ----------Septic Tank {Specify Requirements)-......`- --------- ----- ------------------------- -------------- <br /> s <br /> Disposal Field (Specify Re uirementsl -���.. �i''E3 ---� ---- ------------ <br /> I <br /> ----- - - <br /> 1 -------- --------------- <br /> ------ ------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules aild 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 m4n. <br /> s Co pens ion laws of California." + <br /> -----...Owner <br /> Signed........ ....... . .... . --- - . ...-- --- --......--.-..... • - <br /> .' Title....- - +--------- ---------- ---------- <br /> By------------------------ . ------- ) <br /> (If other than owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------- --------- ---- ----------- ------•-- - ------ - - ----- -------------.-----DATE J§71779_ --- --:------- <br /> DIVISIONOF LAND NUMBS --- - ----------------------------------------------- ....-.-.. ----------------------- - - --------DATE ......................... . ---------------- <br /> ADDITIONAL <br /> -- - -- -ADDITIONAL COMMENTS-------------------------------- <br /> ..... -�- ----------------- -------------- ------ ---- --- --- ------- - ---.. <br /> -... <br /> Final Inspection by: -........ -----------------`--------------- -------- ---------------• --••--------. ...Date----4?`�1-� --... <br /> EH 13 24 + L HEALTH DISTRICT F&5 21677 REY, 7/76 3M i <br /> SAN JOAQUIN LOCA <br />