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�.t <br /> FOR OFFICE USE: j FOR OFFICE USE: <br /> 0 <br /> APPLICATION FOR SANITATION PERMIT <br /> _7 <br /> ------------------------ ------- -- ------ t/ Permit No.7ga� <br /> — l_ <br /> 33 <br /> (Complete in Triplicate) ` <br /> ------------------------- ------------------------------ , <br /> - � pate .Issued_/�_-lam-fig <br /> ----------------------------------- This Permit Expires 1.Year -Date,Issued ' <br /> Application is hereby made to the San'Joaquin Local Healthh trict=fora per_mit-to construct and,install the work herein described. <br /> This application is made in compliance with County Ord inance:No:549 and-existing 'Rules and Regulations: <br /> JOB ADDRESS/LOCT 0 . - -'--------------- ------.ri . -=..:....--.CENSUS TRACT - -- ---- ------ <br /> Owner's Name.--- ---_ -- ----- -------- - - --- ----- --------------- --------------- ---- - - Phone--_-" --------- --7--------- --------- <br /> 0 l -- City - "`;'Zip' <br /> Address.. <br /> x � <br /> Contractor's Name--:------- - ------ _¢. License # .Phone- ' --:`.-------- ----------- <br /> 4i <br /> Installation will serve: Residence Z Apartment House.❑ Commercial ❑ Trailer Court ❑ �i; t <br /> ... ; Motel ❑ Other == <br /> Number of living units:----- <br /> 1"........Number of.be_droom '._____Garbage Grinder-.="_ Lot Size------------------------------------ ---- X F .� , <br /> Water Supply: Public System and name � - --------------------------=Y---------Private [] <br /> Character of soil to a depth of 3 feet: Sand ❑ {Silt❑. .Clay ❑.* PeatEl- Sandy Loam [Clay Lodm ❑ � <br /> Hardpan❑ Adobe❑ Fill Material--._. if yes, type--------- -------------- <br /> (plot <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 see age pit permitted i public sewer is available within 200 feet,) � � i <br /> PACKAGE TREATMENT [ } SEPTIC TANK [ Size_ .___.. _ _�_ S-�______________Liquid Depth---- .__y-__.__.:__.__ <br /> Cap' city_Z�_�--=---Type-l?Material -:: ------No. Compartments---- --------------------------- <br /> Distance to nearest: Well- -.-_--_.-.__ _B©_. :,: _._._._Foundation..____ -EJ -! -.-Prop. Line-"----- ------------71�' <br /> ------- <br /> LEACHING LINE„ [ Na. of Lines.''........ �_____ Length of each line.__._.._. d_ __ _.______Total•Length.___.�"_-1.�_ _*�_ a <br /> y' `D' Box __Type Filter Material_ '_.---_-----_Depth Filter Material----------------'_-.-_._'___ ._ <br /> Distance to nearest: Well_ _____________________"____Foundation.___---.----------------------- - Property Line.--___--.._"--._----- - <br /> SEEPAGE PIT [ ] i Depth----t___:- ._Diameter__ ______________"-Number-----------------..----'__--___ "Rock Filled Yes ❑ No <br /> p• . <br /> i ------------------------------- <br /> Water � , <br /> Table'De th '-------------------------------------- Rock Size------------- -=-- <br /> REPAIR/ADDITION Prev. Sanitation Permit#-------------------------------- - --- Date------------------ ----------------- Prop. Line----------------------- -._. i <br /> Distance.to nearest: Well._:. ..__-.-:-- -.- - Foundation__:______________________ y1 <br /> Septic Tank (Specify. Requirements)----------------- <br /> ~ ----------------------------------------------------.----- •------ --- <br /> Dispose_)-Field[SpecifyRequire_ments]------- ---------- --------------- - ------------------------ - <br /> ti <br /> ` ----=--------- -- <br /> , <br /> w <br /> ----- - ---- <br /> .. - .,_. <br /> `_{[Draw existing and j quired addition�on reverse side] . { <br /> I hereby-certify that I have prepared this,app)atic an nd that-the-work-will be_done-]n--accordance with San Joaquin County <br /> Ordinances, Statei 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 /> II <br /> _,to become subject to Workman's ompensation laws of California.". <br /> Signed- --- ----.:. <br /> -.--.--- ., .-- ---------- --- <br /> - --- ---- =-- . <br /> ------. .-_Owner <br /> 473 <br /> BY - Title <br /> (if s. <br /> " <br /> other than owner] <br /> FOR-D RA MENT USE ONLY I r <br /> APPLICATION ACCEPTED BY----- e__ 1J- -- -- --- -------------------------------------------------------- -----DATE---1_-- -- --- --------- <br /> DIVISION OF LAND NUMBER4------------- ----------------- ; --------------------------- -- --;---------------.DATE ------- -------------- --_-_- <br /> ADDITIONAL COMMENTS-..--!------ <br /> ----------------------- -------- - -- ------------------------- --------------------------------=----------- --- ----------------- ---------- - <br /> t " <br /> ----------------------------------------------------- ----- --=- -- --------------- ------------------------.-- --- --------- --- ------------ ---- ----------------------------- <br /> -- ------------- ------------------------------------ - ------ -- --- --------I-------------------------------------------`--- <br /> -----------------`-------- -- ---- - - --- - -- ----------------------- -------- ,�_ <br /> Final-Inspection•by-------:-- Date <br /> EH 13 24 N AQUIN LOCAL HEALTH DISTRICT F&s 2167.7 REV. 7/76 3M <br />