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-rFOR OFFICE USE: FOR OFFICE USE: <br /> /APPLICA11ON"FOR SANITATION PERMIT <br /> - -'------- ---- ------- ---��'-fid-- ---- _ Permit No.�$�=-�-��-- <br /> --- (Complete in Triplicate) <br /> - Date Issued <br /> ------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby Amade to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compl•+ance with County Ordinance No. 549 and existing Rules and Regulations: <br /> G��t27.11,7 ---.CENSUS TRACT-------------- ---------- ------- <br /> JOB ADDRESSJOCATIt,� <br /> --_ ----- -- -- . <br /> - - dal- -- - - <br /> • • _ -- - - --- --Phone---- ---- --------'-. -- <br /> Owner's Names_ '- - r �,= �- <br /> ----------- - <br /> s // -- ------- <br /> e <br /> ------ <br /> Address------- - ---------- - <br /> -.�0� ,' -- ------' '- Gb .--------City_... " '� Zip - <br /> Contractor's Name. }-----�- - t-. ---- License # one <br /> Ph , <br /> k <br /> Installation will serve: Residence Apartment House.❑ Commercial ['�, Trailer Court ❑ <br /> 1 Motel ❑ Other--------------------------------- <br /> --------- <br /> --------------=---- = r <br /> ` - <br /> Number of living units:_- ,,- ----Number of.bedrooms.---_Yt`arbage Grinder----____--._Lot Size_- .--___--- 9' <br /> Water Supply: Public System?and name--------------- ------- --------------------------- _------------------------------------- <br /> Sandy <br /> -----L- ------------Ci-----Loa ❑ __ Private ❑ <br /> Cha acfer.,of soil to a dept} of3`fee.t: Sand ❑ Silt❑ 'Clay ❑ . Peat❑ 5an y Loam ❑ ay m <br /> ardpan❑ Adobe Fill Material-- -.--.----If yes, type-------------------------- <br /> {Plot plane, showing size of lot,location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: jNo-sep tc tank'or S'depage :pit permitted if public sewer is available within 200 feet,) ` <br /> J ASEPTIC TANK [ ] Size- ------------- -------------:-----Liquid Depth <br /> PACKAGE TREATMENT [ l - i <br /> Capacity--=---=•--- ----------Type_ _::--------------Material-------------- ---No. Compartments----------------------------:- <br /> . . Distance to nearest: We11'-------=------ ------- -------'-- --Foundation----_---__--.-a,--- <br /> ------.Prop. Line------------- ------------ <br /> i <br /> LEACHING LINE �[ l- No. of Lines: ' aye`=+ ngth of each line. ". ' Total Length.- <br /> D' Box...i--- ----TYpe Filter Material----------- ------bepth Filter Material--------:---------- ---------------- <br /> _Property nearest: Well---------------------- -----Foundation---'----'------------------ <br /> Rock <br /> --------- - --.Property Line--------------------- <br /> De th _--'�--..----Diamete� s'-` =------.Number-------------------------------- Rock Filled Yes ❑ No <br /> SEEPAGE PIT [ ] p <br /> } <br /> Water Table Depth- ------Rock Size------------------------------------------------ <br /> ------------ <br /> Distance.to nearest �'Welh°: --- '----------' Foundation---------------------- ---Prop.Line------------------------ <br /> _ , � -----------------------------------Date--' ----'- '--------- ---------' '----1 <br /> REPAIR/AD.DIT,ft* (Prev. Sanitation Permit#,--__.--1-=----- <br /> ' ------------ ----- -------- ------------------------- <br /> Septic Tank (SpeLify Requirements)----------------- - <br /> F �A - ------------------------------------- ------------------------- <br /> Disposal Field`(5pecify Requirements)---.___f�C -- N � wvr i <br /> �" --- <br /> C ----- j -------------------------- --- <br /> - <br /> -----= = <br /> ------- <br /> - '`' "` --(Draw existing and required addition on reverse side) <br /> 1 hereby certify that,l have prepared this application and that.the work will, be done in accordance with San Joaquin County <br /> Ordinances,' State Laws, andi Rules and Regulationso4;the San Joaquin Health District, Home owner or licensed agents <br /> -�; [ <br /> signature certifies the following: <br /> I "I Certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in suchmanner as <br /> to become subject to Workman's Compensation laws of California." <br /> ned- ----------- <br /> -------- " Owner ] <br /> F Sig _ <br /> Y � F " :Title--- - -------------- --------- ------- --------- - <br /> B 4'----: - <br /> (if other than owner) _ <br /> FOR DEPARTMENT USE ONLY <br /> j APPLICATION ACCEPTED BY le-.l a,.,C __` ----'�------------ ------------ DATE._.- W .. <br /> t EDATE <br /> DIVISION OF LAND NUMB -- ----- �Z' "',.-�"� u - <br /> �P. E1 _. ------ - --------- --------------------------------------- <br /> XMADDITIONAL..C-( E ---------- - --- -1 -- <br /> U <br /> ------------------ <br /> -------------- ----------- --- <br /> ----- ---------------------------------- -- <br /> ---- ----- -'--------- - --------- ------- _ Date <br /> ------------------------ --------------------- <br /> Final Inspection -_- :;------ F-s 2r6 Rev 7/76 3M <br /> eN 13 24 '�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br />