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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ........................_. 7�_It <br /> (Complete in Triplicate) Permit o............... <br /> Date Issued..S4 7 <br /> ..--- .............•---- <br /> This Permit Expires 1 Year From Date Issuer! <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 /> uj <br /> JOB ADDRESS/LOCATIO[N7�.f_... ... r7t�E'[f'. ...5DU' ` ll.ry <br /> P47&L....CENSUS TRACT...--- __....... <br /> Owner's Name.., N 0(_._(r AW_AS� <br /> ....... _.... Phone _..... <br /> Address. - -1�?3 s' �-1i2�.rlr.�..��tu. .. ... 1_1Art-i ).......... __City........... ...................... .........zip--- ---•----- <br /> Contractor's Name -- -__ -.._ 0U3it.VFi ........License #-.-- -- <br /> ---•� ................ .. .-�----�------•-�------- - ..............-Phone---- -.....-- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-----$_AZ_n?........... . . <br /> Number of living units:-- Number of bedrooms............Garbage Grindw............Lot Size.. .-..------ ---_-------_-----.-------------.... .... <br /> Water Supply: Public System and name...... ­--------------------------- ...........................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe�q, Fill Material.---- --- _If 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 available within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK Size.. --.--I'N........... ........ ........Liquid DePth... ... ... ....__1 <br /> Capacity__I.*2o6L Type.-.I YC C�� -------Mate-rial. -,.0c-.Y4..c_No. Compartments..........�`� ............. �I <br /> Distance to nearest: Well.............Zq ............... Foundation.... _.t 0. . ..........Prop. Line.----... _! ." ......--...`` <br /> LEACHING LINE [ ) No. of Lines....... .......1.--------... Length of each line -. ....c 0.........- --.-Total Length ......4 ................ ......... \ <br /> 'D' Box..'..._..Type Filter MaterialDepth Filter Material...- - . <br /> Distance to nearest: Well:_.: °`'........--_Foundation..-..-....,a fi?�......._... Property Line-------- - •.............::... <br /> SEEPAGE PIT [ ] Depth.................Diameter....................Number.._ ..-----------------------.- Rock Filler) Yes ❑ No ❑ <br /> ------••--------------Rock Size---- .� ...................... <br /> Water Table Depth.--��-------...-�-�------ -•_- .. - ...-..-- <br /> Distance to nearest: Well..................................... Foundation...... -...... ..........Prop. Line........................ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------_--------------------------- -----Date_.........- -----------.-----..-_--.------) <br /> Septic Tank (Specify Requirements). :.-- . .._ . .... <br /> Disposal Fie (Specify Requirements ....... - ------ ••-----•---•------•--•-•............ .. ..............------------ • - . <br /> -------------------- ------------------------------- ---------------------------------- --•----•----------- ....................................I-------------- ...... •------- -------- <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 done in accordance 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: <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 bje<to or a s Comps cation laws of California." <br /> �� t till�j <br /> Signed�-- ............ <br /> --...... .. .............�--�-- --....... --- ---- -.._..-------------------------Owner <br /> By........... .. ..........•---- .............................. .............Title..... ---------------- -------......---... -------- •-- <br /> (If other than owner) <br /> FOR DEPARTMENT, USE ONLY <br /> APPLICATION ACCEPTED BY ( .........:...... _ + ....... <-. � C= --.DATE rS.`"�' 5..... ...:... :....._.... <br /> r <br /> DIVISION OF LAND NUMBER......... - •.....--.. _ _/-. --------.DATE-------- ---------------- - <br /> ADDITIONAL COMMENTS.------- ................ ---.....................----------------- <br /> ---- .. ..------------------------------:.-.------------- -- -------------..._:--- ---------•-- ....... --------- - ------ . <br /> Final Inspection by:- - ._...._. --------------------- ----Date --------------- .-----......- - --_..- - - - <br /> FH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/75 3M <br />