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FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------- ---- ---------- --------------------------- <br /> {Complete in Triplicate} Permit No----7.__._"-� <br /> -------------I----------------------------------------- <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 /> I <br /> JOB { <br /> BADDRESS/LOCATION_ 1� __ /Sf ,---- __ ---- -------------------------.CENSUS <br /> n <br /> . _v _ <br /> TRACT------------------------------ <br /> -_7 <br /> -III--"""---_ <br /> -.------------ ____- <br /> s - - - Phone 73;J'7- ....... <br /> -----CityOwner' _Address--S" <br /> ..... . <br /> Contractor's Name_.._/__.._ _ - ' ____. __ >� �.-.__License #_Z_r�3 _ S .___Phone _ '-�� ; <br /> r <br /> Installation will serve: / Resident �� Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------- =-------------------------------- �-n <br /> Number of living units: <br /> r--------Number of.bedrooms-- ---Garbage Grinder--:' __Lot Size-------�`% vJ <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 ❑ _r <br /> Hardpan'] Adobe Fill Material_..__ ______Ef 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 availle within 200 feet,] <br /> PACKAGE TREATMENT [ -] -!--SEPTIC TANK [ ] Size----- -: Y -�-' ------"---.-Liquid Dept__________________ . <br /> Capacity- f`�� T e,-�-L _ _-Mate•rial''._-_ _ Flo. Compartments______. <br /> s P Y ------------ <br /> ---------------- <br /> -Distance <br /> ---------- -- YP <br /> � f f <br /> -Distance.to.nearest: Well_._..__�y©____--__. 'Fou//ndi�tion_.: --------Prop. Line------ _ _____________ <br /> LEACHING LINE. [ ] _ No. of Lines___... ____-------___..Length. each line-.=:_ Z��__�,-_---„__„Total Len <br /> �_________�__ <br /> 'D' Box---_f------Type Filter Materia—,41c :4- ---Depth Filter Material_.______- ---- ----------------- ---- ---------------- <br /> is � <br /> f l ------ <br /> Distance to rest: Well___.__ __. Foundation.__ _` ��_-----------Property Line________ _ _____ <br /> SEEPAGE PIT [ ] Dept . ---_Diameter.___ . _______Number, ____ ___ k Fill Yes < No ❑ <br /> Water Table.De th-- --------------=--------------------------- Rock Size Y l <br /> f <br /> Disfance.to nearest: Well._"-.__='' Foundation_';-____ _- <br /> /. _ Prop. Line------ ------------------ <br /> REPAIR/ADDITION {}'rev. Sanitation Permit#------ Date = ------------- 1 <br /> i <br /> Septic Tank (Specify.Requirements). --------------- ----------- ----.,---- -------------------------------i <br /> Disposal Field (Specify Requirements]--------- --- ----------------------------- --- -'-- -------------------------------------:---------------- ------ <br /> I <br /> ------------------------------------------------------------------------ ----- ------------=--------------I . --------------------------------------------- <br /> ' ---------------------------------------- (___1-- ---------------------------------------------------------------'------------i-------------------------------------------------------------------- --- <br /> (Draw existing and_required addition on reverse side) r <br /> I hereby certify that I have prepared this application and that the work will be46ne' in 7acc6rd'ance 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: = rs r <br /> j 4f <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such spanner as <br /> to become subject to Workman's Compensation laws of California.” +.J” F i <br /> i ire <br /> Signed :_ ------------------------ --- -- ------------------- <br /> - Clwner <br /> --- ------� -- - _Title = F <br /> - - --------------------------- <br /> 4 } 1 <br /> Of other than owner] '. <br /> " FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = ----------------------=----------DATE -.3- .? <br /> DIVISION OF LAND NUMBER----------------------------------- -• ---- ---- - r�'----- ------------- ------------.DATE ------------------------------- .------ ---- <br /> ------------ <br /> ADDITIONAL COMMENTS_..-------- -�_A--'� ---tl -°x" ) <br /> ,. <br /> ------`-------------------------------------------------------- ------------- --------------------:------------ <br /> ---------------------------- <br /> i -----------------------------------------= r- ---------- ------------------------------------------------------------------------------------------------------- <br /> <. ;E --•_- - --------- --------------------------------------------- �= 4 <br /> r . _n,:; f <br /> Final Inspection by: - a "--- I -�- ----------- "------------------------------ ----- -Date. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2.77 REV. 7/76 3M <br />