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FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ........................................---........ Permit No...A-PYT <br /> (Complete in Triplicate) <br /> --••----_-__----•-••---•--•--------•-------- <br /> i Date Issued-- <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> 1 <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 /> pt <br /> JOB ADDRESS/LOCATION....c�--c?�--a2._-731...- .: .Ll .... -.-- - CENSUS TRACT..... <br /> Owner's Name-- - : - - ---------- -Aa--- -------- .... r .... <br /> .....Phone <br /> Address-- --fes Q'.�-. ...._..:. ~:_ ,rCity (/G4... ..--.....Zip_ � _..- <br /> f(o <br /> Contractor's Nam _-...-1-� .'. _ . . ...............License Phone..:5,:� ;7, AKA5 <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-- ---------------------- <br /> Number <br /> - ------------Number of living units:- f-...:__---Num'ber-of-bedrooms7—Gafbage Grinder . Lot'Size. ....---.---. <br /> Water Supply: Public System and name - ... ..........._... ---.-------- -- ......-----.._. ------------- - Private <br /> Character of soil to a depth of:3 feet:., Sand i�5ilt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe D Fill Material.. .... ....If yes, type-------------------------- - - - <br /> {Plot plan, showing size of lot, loccition of system in relation to wells, buildings, etc• must be placed on reverse side.) r <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> a " f � <br /> PACKAGE TREATMENT ( j SEPTIC TANK [ ] - Size ----/r oC9----------------------------------------Liquid Depth. '_.._.'----..-... <br /> Capacity..�a _c7------Type_- ... .........Matarialaoo ...--•-No. Compartments.--- ----- - --------------- <br /> - -:A' f <br /> Distance to-nearest:-Well: /-_..:.- ..... .:.. ........ Foundation:r Prop.Line-------------------.---..- . <br /> LEACHING LINE [ ] Na: of Lines '---:. -------------- --- Length of each line.-__-�--_-..----- ----.---Total Length �1?149t <br /> LEACHING <br /> Box:_:'.'._¢ ..Type Filter Material-------- _- -- ---.Depth Filter Material.---------- ---------- ----------------------- -------- <br /> Distance to nearest: Well--------------.-`--.- Foundation---------------''.�---. :- Property Line---------------------.............. <br /> SEEPAGE PIT [ ] Depth.-.. .........Diameter__...................Number-.-.-______-_-_- --_____--- Rock Filled Yes ❑ No <br /> Water TableiDepth----------------- ---•----- -- Rock Size. .---.....-=--- -------- <br /> Distance to nearest: Well-------------------- ----------------Foundation-----...........--. --. Prop. Line---------._------....__. <br /> REPAIR/ADDITION iPrev. Sanitation Permit#-------------------- --- -.: Date.- .---__- r-.........--------- <br /> N <br /> -:- ] <br /> Septic Tank iSpecify Requirements)_.............. - -------=----- ------------ ------------•---- ---;----- = ----- -------•--- ---------- - ------- <br /> Jr � s � * <br /> Disposal Field (Specify Requirements) _--________ ------ = - - _:: .:, <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 clone in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules`" and.-Regulations; of_th f-.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 subje to Wo mclns Co pensation laws of California." <br /> Sig - ------ .tom...... ...... ------ ---- --Owner <br /> .....-.Title.. <br /> By .--- ... <br /> (If other than owner)r-._,,,,,,,-,,._ <br /> t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ............_... <br /> DIVISION OF LAND NUMBER-------- ----------- ---------------------------- -.-.._._..._. DATE - <br /> ADDITIONAL COMMENTS------------- - ------ --... <br /> :� ------ ------------------------ <br /> ............... ......­­. ..... ........... .... ........... --------------......__........-- ------------- <br /> ----- ---------------------------------•---------------------'-. `,V <br /> i ----------------- ---------------•----...... ----- ----- - Dat Y <br /> Final Inspettion by:.- -- -- -------------------- -------... a -..-- - - . 71 6 3M <br /> Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 214" REV. 'i' <br />