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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No,------71- d-- <br /> -------------------------------- -------------------- - (Complete in Triplicate) <br /> ---------------------- ---------- ----------------- Date Issued <br /> F, _ <br /> 7 <br /> This Perms it Expires[ Year.;Prom_;I}ate`issued <br /> -------------- -- <br /> Application is hereby made tSan Joaquin Local Health District for a permit to construct and.install the work herein described. <br /> o the <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: , <br /> � ,-- CENSUS TRACT - - <br /> `� --- . ei <br /> -- ----------- <br /> JOB ADDRESS/LOCATION--- - -- <br /> Owner's Name------ -- ------------------- --- <br /> --. hone--------------------------- <br /> Owner's <br /> -------------- -. -_ <br /> �s�f ��, P <br /> r! �/ • . <br /> Q --- --- - -------- -----,-- ------------ <br /> Address <br /> ----- -. p <br /> Address _ <br /> � . <br /> City ___ _ - Zi _ <br /> ens Phone--------------------------- ------ <br /> = :Lic e <br /> Contractors Name-_: __-- le $ <br /> ..• - F. . .- i. E <br /> Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> . of - <br />� � � .. . -•- z el ❑ -Other ' ------- '---- -- -- -----=- ---" -� <br /> Garbage dp--.' ...I <br /> Number of living units:_____.. Number of bedrooms'_: ge Grinder.- -Lot Size___.- neat <br /> --------- -------- ---------- <br /> Water <br /> Water Supply: Public System and name----------------- - ----------_---.---- -- :----------------- _ <br /> -- Private <br /> et: - San Silt Cla peat tySandy Loam ❑ Clay Loam ❑ <br /> p ❑ Y ❑ , <br /> Character of soil to a de th of 3 fe Adobe Fi11•Material----- If es; -pe'l`t"-- -- - -- --------- <br /> t Hardpan ❑ ob lJ <br /> (Plot plan, showing size of lot, location of:system in relation to:wells, buildings,•etc. must be placed on reverse side.) # <br /> _` - -...,J.... <br /> NEW INSTALLATION:' •(Nbssepticttank ,or seepage pit perm'ittedr.if�pubais�sew.er is vailable within 200 feet,] <br /> . , .� i... . W liquid Depth-- �------ -------: <br /> Size._ <br /> PACKAGE TREATMENT [ ] <br /> - SEPTIC <br /> TANK ["] # �t <br /> o -Compartments_.-----�'------------------- <br /> . Capacity ._ TYPe.=.- -:-- -- :_Matenal-_w �Lfr'y <br /> N <br /> ' - _ ----------------- <br /> Distance.to nearest: Well- .------:--� --.��--'---==:, - ndatfo�--�=d -Prop. Line---�t�--------=-------` -- <br /> l=-----:Total Length.__.-�------------ <br /> --------- = <br /> No. of Lines.-- Length,.of ..- <br /> LEACHING LINE [']. � ., :� i <br /> FilterMaterial_--- -- ----------------------------------------------------- <br /> 'D' <br /> - - -- <br /> D' Box __-_ --- Type Filter Material Depth 1 .. - <br /> - <br /> 1• <br /> --- Rock F111 N <br /> Distance to nearest: Well_ Foundation + �� Prope;�ty Line--7-11 ------------------------- <br /> Distance <br /> - <br /> lol ; <br /> R Ye <br /> [ ] Depth-'ax - i eter-' = ---!. Number , <br /> __ <br /> Size <br /> . .j <br /> ---- ------ <br /> a: Water Table:Depth ------------------- Rock'� S e,.. <br /> If <br /> Distance,fo n'e'arest: We1i ---Foundation-- - ------•- ----!-.Prop. Line_. <br /> r .. <br /> -'---- -------- -------------- <br /> ------------------ <br /> REPAIR/ADDITION <br /> ---- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-_�'---------= ----='--"---- - , <br /> f ..... - <br /> ----------------- -----L-- <br /> = --=-------------------- --•-==:---- _----- :. <br /> k Septic Tank (Specify Requirements)----- --- -=-----=--=- ---. <br /> Disposal Field (Specify Requirements)_--_-___.- -- ------------------------- <br /> - --- -----------------------------------•--- <br /> • � i • <br /> -- <br /> ------- <br /> ------ --------- <br /> -------- -- - - ---- -. -. - -. - -. -- - - <br /> ------------------------------=-- - - ------ - <br /> --------------- ------=------------------------------------ - , <br /> {Draw existing and required addition on reverse side) F <br /> I hereby certify that I have prepared'this application and that theworkwill 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 perforrrmante 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 /> l - r <br /> Sighed-- Owner <br /> ` <br /> Title---------------------------- <br /> By <br /> (If other than:owner) <br /> ' FOR:DEPARTMENT USE ONLY, <br /> a <br /> DATE <br /> ALICATION ACCEPTED..BY - --- ----- <br /> DATE---------------------------- ------- ._ <br /> PP - <br /> _ . -- -- <br /> DIVISION OF LAND NUMBER.------'.---------- -=---- --------- - - :_ __w------------ <br /> ADDITIONAL COMMENT ------------- <br /> ----------- <br /> -;-----=-------------=-- --------------------- <br /> . - - - --- - -- = <br /> -- <br /> ------- - <br /> -------------------------------- <br /> --------------­---- <br /> ----- <br /> v <br /> ° = - <br /> �I . . - --- ----- - ------------- ------------------------- --- � <br /> --- ate _- --- <br /> Final.Ins Inspection-by: � -'- -..------------------------------ ------ <br /> _ F&5 21677 REV,7/76 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DI ICT <br />