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rFOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No 7_;7 <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- Date <br /> lssued__5�_ __--_77 <br /> ________________________ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin-Local•Health-District fora permit•to•construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existirtig Rules and Regulations: <br /> JOB ADDRESS/LOCATIONKGG <br /> .5,�7. <br /> - ----74_c:7,5,,LA---- ---------------- -- - -...CENSUS TRACT-- ---------- ------------_---- <br /> Owner's <br /> - ------...._-.Owner's Name--------- --------------------------------------------------,- : Phone---- ----- ------------------------•- <br /> Address .�- ------ /?A Cityzip <br /> Contractor s Name......... ---------------------------------------------License ------- <br /> Installation <br /> ----Installation will serve: Residence R Apartment House ❑ Commercio I Trailer Court ❑ _ <br /> 9 .,Mote.L [;] —_Other_,x.o,.;--- ------ t- -4 <br /> Number of living units:___.- Number o edrooms-��,� . . g ; <br /> -. �"'�U'arba e Grinder_.,.--).,.:Lot Srze----------------------------------- ---- - -------- <br /> Water Supply: Public Sys and`name----------------------- ------------- --------------- - -------------------------------------------------------Private ❑ <br /> PP Y� Y ` � ..���i - ,- -g , <br /> Character of soii.to a depth of 3 feet�Sand ❑ Silt ❑ ,- Clay,❑ Peat ❑ Sandy Loam ❑ Clay Loom ❑ <br /> Hardpan ❑ Fill Material.- ----- -.If yes` type_-_____________________________ <br /> (Plot plan, showing size of lot, location-of 'ystmin relation'tobwells, buildings,`etc. must be placed on reverse side.) <br /> NEW INSTALLATION: -,(No septic tank or seepagepit-permitted if public sewer is available within-:200 feet,) !� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ize: a,' ------ _______________F,i-Liq.uid.Depth` __._____._____ <br /> CapacityAICJ�?-------Type- '� 4c---------- Material_:------------------------No. Compartments------------ <br /> ► x"�/ <br /> Distance'to nearest: Well--------- ------------ .Q_±_______<----Foundation-._,a _.________-__Prop, Line.-----0--_----__-_------ <br /> LEACHING LINE [ ] No. of Lines---- ea <br /> Length.-_------~=---. of h p-------- _-----.Total Length ----- _ 6------------------- S <br /> D' Box----/------Type Filter Material) x Depth Filter Material----------` ------------------- ----- <br /> ----------------------00 <br /> ------ -------------------------------------00 <br /> -Distance to est:Well__ _______________ ,+_-Foundation--- C __ ------.---Property Line ---- ------a <br /> ------- <br /> SEEPAGE PIT [ ] Depth----------------Dir'ameter------ Number_..,____•___ ._._______N_ Rock Filled Yes ❑ No F] <br /> Water Table Depth----------- - �' ',.', ---------Rock Siza <br /> tiDisfthde to-nearest: Well------------------------------------- Foundation---------_---------------.Prop, Line------------ --- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------_______------.----T - <br /> __-_.:_ ------ ------- ---------------------- _.__] <br /> Septic Tank (Specify Requirem encs)---- ----------------------------.----------------- =---------" ------ ------ ------------------------------------------- <br /> Disposal <br /> --- -------------------------Disposal Field (Specify Reg6irements)----------------- ---- ------- -- ---------------------- --------- <br /> --------------------- <br /> I <br /> -------------------- <br /> 1 t - fir <br /> T <br /> ----------------------'------------- -- - --------------------------------------------------------- --------------------t-------------------------------------------------- -------------- <br /> --------- ---------- -v---------------------------- ----------------------------------------- ------------ ------------------ --------------- - ------------------------------ <br /> [[Draw existing and required addition on reverse slide] <br /> 1 hereby certify 4hat-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: Y <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 t rkmanIs Compensation laws of California." i <br /> Signed--- � _ /----------------------------------------------Owner <br /> l <br /> B -�---------- f---- Title <br /> ![ff other than. owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLKATION=ACEPTED BY - r --------------------------------- -------------DATE.�j�- -�Z ----------------- <br /> DIVISION OF LAND NUMBER----------------- -- --------- ------------ ---------- ---------- ---------- ----------------------- DATE---- <br /> COMMENTS - --------- ---------------- <br /> A, <br /> --------------------_-----------.-----------------------------------------...------------.----------------- <br /> __ ____--- <br /> ___ns ectian b__________________________ __________________• ______---------------------------------------------- .-_____.____._ <br /> Final IO �-- 7 <br /> ------------Date ? ------------- <br /> P yf' <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M <br />