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FOR OFFICE USE: FOR OFFICE USE: <br /> I`. , APPLICATION FOR SANITATION PERMIT t <br /> ------------------------- ----- II <br /> ---------------- <br /> Permit <br /> (Complete in Triplicate) �---� <br /> ---------------- •-•--------- .--------- Date t <br /> •...............................---- ------------------- This Permit Expires 1 Year From Date Issued <br /> :r <br /> Application is herebly 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/LO LOCATION <br /> _.CENSUS TRACT..-.....- <br /> Owner's Name. r?�.,� 5 .-.. r..G E.[2....._- -- ----Phone --- <br /> .----...... <br /> Address------ !3_.4Y.�.. . '.A?././'�- V1-f_W' ................... ----------- ............. <br /> Contractor'sName.l�..... _(f.Ba a.`•(rA C�& ------------........ ...........':.. ....---License #. -•------ -------------.Phone..f ...... <br /> Installation will serf e: Residence ® Apartment House ❑: Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------- -------------------•--.------ ----- <br /> - t 3 <br /> Number of living units-----------------Number of bedrooms- �- Garbage Grinder-....---:...Lot Size rS.. :L 3' =-_,-- ------ <br /> Water Supply: Publi� System and name_......-.- Private [ <br /> Il' <br /> Character of sail to a depth of 3 feet; Sand 0 Silt❑ Clay ❑ Peat ElSandy Loam E3Clay Loam [� <br /> Hardpan ❑- Adobe-R,.:-Fill-•Mater-iol-7..- <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..----��.- .� �.._. '!"a1� ^ Liquid Depth._-'--.-.------ <br /> Capacity------ ...°-----------Type ---------------- ....-Material.........................:No. Compartments.__2 L....................... �1 <br /> Distance to nearest: Well------V O(2.-,._�"� . . . ..........Foundation............ ... ...._..Prop. Line ` <br /> LEACHINGf <br /> LINE [ ) No. of Lines....-�..-------------.-.- .Length of each line._..�.Q..-.-.--•-•---- -�--Total Length _,�- ------------ -- ----------• � <br /> Line__ - <br /> D-sstance..to nearest: Well............. ............:.foundation----------------------------Property � �- <br /> _ <br /> D' Box--.._ ....._.Type Filter Material_............ . ..De Depth Filter Material.-.-......... - -.. ----------- -•. <br /> SEEPAGE PIT [ ] Depth--------------._Diameter--------------------Number--.------------.--------.------- Rock Filled Yes ® No E] <br /> Water Table Depth.--g' ---------------------------•------ <br /> -------- -----Rock Size.-. .�^_...... <br /> . Distance to nearest: Well------------------- ------ -------- •------Foundation.......-........ Prop. Line----------- <br /> - <br /> REPAIR/ADDITION+(Prev. Sanitation Permit#----------------------------- --------------- --....Date----.-...-••------------------- -----) <br /> Septic Tank (Specify Requirements]........`_-------------------- ....... ........... <br /> ------------- <br /> Disposal Field (Spe`fy Requirements) ............... .. - <br /> �I ...................... -------- ----------------------------------------- .......-.........-•---•---------------­--- -------- <br /> ---------- <br /> I� -------- -- ------. - ------- - -----------------------------------_ _ _ -- <br /> _ = Y . <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 i <br /> Ordinances, State 11 Laws, and Rules and Regulations of the Son Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: i <br /> 1i. <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 Workman's Compensation laws of California." <br /> r p <br /> Signed..----- ��..-----�f..�C,..�.P..f.�-............-.....-.......... ------ .....Owner <br /> 7��'!e. ......... <br /> U <br /> `` ------------------••------- ----------------------Title--- �.ta� -� t �y ``..--. ...---• ---- ,.. <br /> (If other than owner) _ <br /> - � R PARIMMN L1SIr NLY <br /> ,E � -- <br /> APPLICATION ACCEPTED BY---------- _ ---.....DATE ------- ------ --------- <br /> _DATE. <br /> --- <br /> p. <br /> DIVISION OF LAND NUMBER-------------- ----- ------------ ............................ DAT .... <br /> ADDITIONALCOMMENTS. ..............................................................................--....------- ---------------------- -------------------------------- <br /> '11. ----•-------------------•-------------- ----------- ----------------------.....-------- ...... <br /> ---------- ----- ------------------- .... <br /> iM. ------------ ---- <br /> li _...... = .....-- . <br /> ------------•--- <br /> IM ----•----- <br /> .......................... j <br /> � _ -------------- <br /> EH <br /> ---- ---- - ..Date./..�-�--�.--.... ......................... <br /> Final Inspection by:-... �---.... - _ -•-------------•....-_....- -------- - ----- - <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 Rev, 7/76 3 <br />