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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ------ <br /> (Complete in Triplicate) Permit NoZF-_ 4.-� <br /> This Permit Expires 1 Year From Date Issued Date Issuedll.:. . <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 /> JOB ADDRESS/LOCATION . "-7 e) <br /> -CENSUS TRACT .---- <br /> Owner's Name ...... <br /> .-....... ....... - -........-.......... •---- Phone� �- <br /> Address. . /P �9 <br /> --------- <br /> --S <br /> -- <br /> Cit • 6 / l.�oLO <br /> Contractor's Y...- r...tti- ..�`�° zip <br /> Name_.t�.L�.���.h...l.-�..�_�.d � / . <br /> ...... ....... ---.License #.."-------...---- Phone."V4+"_3'.53.-5.?... <br /> Installation will serve: Residence <br /> ❑ Apartment Haase ❑ Commercial ❑ Trailer Court,)7�' <br /> Motel (] _Other---- -M <br /> .Number of living units:.._/9 ..._Number of bedrooms.......... .Garbage Grinder.-.-------..Lot Size---.. r�...A C 1^e`'S <br /> - ---- <br /> Water Supply: Public System and name.. ..... .."5....:4_�' V(/, rr --------•- ...... <br /> --...---•--...------ ..------- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam [] Clay Loam ❑ <br /> Hardpan [] Adobe X 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 <br /> --------_ [ ] Size.----- ----------------------------- -_---Liquid Depth.------ -------- --------- <br /> Capacity------- - --------TYPe---------- -- - ------Material----.---------------------No. Compartments.----•.... •----- <br /> Distance to nearest: Well................. .... ..................Foundation".-------- - -- <br /> . . Prop. Line.........................�} <br /> LEACHING LINE [ ] No. of Lines ---------------•--_--Length of each line.....-...."._.--""-_-'-- <br /> `�-- -- -.. Total Length .. -------- <br /> D' -------_------------ <br /> Box ........ Type Filter Material........ ...........Depth Filter Material..."- _--. <br /> SEEPAG Distance to nearest: Well---------"""- "___.Foundation----------------- <br /> SEEPAGE <br /> ----------- ` <br /> ..... ..Property Line..... ......... ............._....+, <br /> E PIT � " <br /> Depth.-.. �---..Diameter.----."_. Number-------------/---------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth._----------- .-.. ---- s <br /> 11. ...- """_-_- " Rock Size <br /> Distance to nearest: Well.----•---n.Q . ) <br /> k ...........Foundation, <br /> ^oe <br /> `F <br /> --. ---- ....Prop. Line........... ............ <br /> REPAIR/ADDI'TION ]Prev. Sanitation Permit#-.---.---7e -/dg9-"- <br /> ----- --•-".Date------ _ 1 <br /> Septic Tank (Specify Requirements) <br /> --------------------------------------------.-. . . <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 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 certiifies 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 subject to Work n's Compensation aws of California." <br /> Signed-- -- -" ' "-Owner <br /> -- <br /> By-------------------------------- --- ---- ------------ ...'Title---------- - . <br /> (If other than owner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-""""...... <br /> -- ------- ----- ---------------�-DATE --- .. ..---- � -- -- - - ----- <br /> DIVISION OF LAND NUMBER.------- <br /> ------------------- ----------- .DATE.-------- -... <br /> ETIONAL COMMENTS,-....-.."------- <br /> ------------------ <br /> --- --------------- ----- <br />-------------­---- - -- -....---- <br /> Finall -" <br /> Inspection by;.. -------.-.-. <br /> -- - �`�� �� <br /> ------ - - --------------------------_-- -- -- ---pate --- ....------- <br /> EH i3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FSS 21677 REV. 7/76 3M <br />