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FOR OFFICE USE; FOR OFFICE USE: <br /> _ 3 Pte_" APPLICATION FOR SANITATION PERMIT ' <br /> (Complete in Triplicate) Permit No.7 -= :7 <br /> ------------------ ----------- ----------- ---- ---- i - �� 7 <br /> hi s_Permit.Expires 1 Date Issued_.. --11—Year-Fro -- _ _ <br /> Application is hereby made to the San Joaquin Local(Heal.fh,Distrlct for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance Nof549 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATION.--- --- <br /> ----CENSUS TRACT---------- <br /> Owner's Name-- --------- ---- --- < <br /> ._.. Phon <br /> ------, -- - -------- -------- <br /> Ad -- l .Z_ U' r_! City - <br /> �� � 9 <br /> ------ --------- <br /> Contractor's Name.--_...-- �_�r !'2Lt4a- F�- � ,�..� <br /> P - ----- ---License#----------------------------Phone:.�� --Med7 <br /> Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ <br /> y Motel ❑ Other ------- ------ <br /> - <br /> - <br /> Number of living units:-" ------ Number of.bedrooms.__ <br /> i <br /> -- __..___Garbage Grinder_-_---------Lot Size-__.._r - <br /> Water Supply: Public System and name----=--------------- �. <br /> ------------ '----- .. <br /> Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat 0 Sandy Locifn ❑ Clay Loam- { <br /> -~4 -�-...� Hardpan ❑ Adobe Fill Material-_.._' If 0. t <br /> j Yes, type.. ----------' <br /> (Plof.plan, showing 4s 4e•of lot, location of s—siem'in-relation to:wells, R <br /> Y buildings, etc.,must be plated,on reverse side.) <br /> NEHi1,�INSTALLATION: (No septic tank or seepage pit permitted if public sew' <br /> - is.available-within.200 feet,)." I <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ f r a j t l Size... - -- ' h ,�_: <br /> : :__ _Liquid Depth.---', <br /> P - rIt ------ ----- <br /> Capacity----- --- --- ---°Type-- Material 1- <br /> No: Cartments `0�• <br /> ---- ---- <br /> Distance'to nearest:.WeI1. �---------------------Foundation.--�- ----}-�,­Prop. Linea i------------ <br /> LEACHING <br /> -_ -LEACHING LINE [ ] No.. of Lines-;,--------------------------11ength of`e ch fine.- •_` _.--------'----.Total Lerigth ---------------------j -----`-- <br /> P <br /> D' Box-------------Type Filter MateriaL�_ <br /> ------------Depth Filteaerial__------------------ <br /> Distance to nearest: Well-- ----------,-- -----T-_Foundation._--------------------------Property Line----------------- . <br /> SEEPAGE PIFDiameter— ... ...: : P <br /> [ ] Depth = :-- -Number----------------------------- = Rock Fi�e`d Yes ❑ Na R <br /> - - M <br /> Water Table Depth--------------4------ -- --- r <br /> �, ------------------------i---Rock Size ' <br /> ------------------------ --------..-Foundation--------=----------..----.Prop. Line------- --------- <br /> REPAIR/ADDITIONSanitation Permit#-------------- ' <br /> Distance to nearest: Well.___.__. <br /> / (Prev.I Date_ ---------------------<----------- 1 a ; <br /> --------------- <br /> c�,:. <br /> fSeptic Tank (Specify Requirements).- _� <br /> f; , _ <br /> --- ----------------------- <br /> ---- <br /> ------ <br /> Dis osal Field IS e�Y�Requiiments} - -- _ - -------; -------- ------- ------- -- ---- <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. Nome owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the <br /> erfo ante-of`the work for which this permit is issued, .I shall not employ any person in such manner as <br /> to becomeff�ubje F ox. rT en's Co pensat oa, law f California." <br /> Signed__._ ,__ .. ' - I - <br /> Owner <br /> BY------------- ------------------------------------- -- ---------- .Title_ <br /> - $ <br /> (if other than o ner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.____- <br /> DATE J- ------ <br /> DIVISION OF LAND NUMBER:.. -----'------------- - DATE.. <br /> -- ------------------- - <br /> DITIONAL COMMENTS__ _ <br /> --------------- - <br /> ------------------------------------------------------------------------------------------------- ---------------------------------- <br /> ---- <br /> ----------------------------- ------------------ - - --------------- <br /> Final Inspection by ----- <br /> ` a . R ---------------Date_._ <br /> _ / <br /> EH 1$ 24 SAN JOAQUIN LOCAL HEALTH DISTRICT _ F&S 21677 REV. 7/76 3M <br /> (ifs <br />