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' FOR OFFICE USE: FOR OFFICE USE: <br /> ,PPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) 9 � �/ <br /> Permit No..2...:.............. <br /> --•------------------- --------------------------------- <br /> Date Issued_.... '.... <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <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 Or nce No. 549 and listing Rules and Regulations: <br /> 0" <br /> JOB ADDRESS LOCAT N -- ------------------- 0 CENSUS TRACT <br /> / r , <br /> Owner's Name------ ---1"-----a« ----- Ca�G-- -------i-r-- <br /> -- --- hone-- -7 -------------------- <br /> Address � U� City -A� --------- ZiP- <br /> ---------------------------- <br /> Contractor's Name_-__S/_..9.."at X ____________________________License ------Phone--3------6---F--3----- <br /> ---------- <br /> i- <br /> - <br /> Installation will serve: Residence J;--Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other---------------------------- ----------------- <br /> Number of living units:__/----------Number of bedrooms_ _..._Garbage Grinder------------Lot Size....._... ....................._________________________ <br /> Water Supply: Public System and name-----------------------------------------------------------------------------------------------------------------------------------Private'-dg.. <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam F� <br /> Hardpan ❑ Adobe ❑ Fill Material............If yes,type________________________________ S� <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: ,�`JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,J <br /> PACKAGE TREATMENT , [ j SEPTIC TANK <br /> Cyd : ` =, :s'1�3-. S'� iquid Depth.- - u---------------- ` <br /> Capacity-/;? ---•---TYPe----1-u4sd- ------Material-------C._d --------No. compartments---�--------------------------- <br /> � ff I 1 <br /> Distance to nearest: Well-----�0 ---------------------------Foundation.. _[.0-__---__-._.__-.Prop. Line.--. S._____.--------- . <br /> ``�O / ! <br /> LEACHING LINE ['j No:-of Lines.3------------_-------- of each line.____7__-__.------.___T....Total Length._._1 -1--------.______________-_ <br /> D - Type"filter Material�x_. -------- Depth Filter Material __ ------------------ --------------------------------------_ <br /> Distance to nearest:.aNeH_1t_.._--------------Founds#tori_: / __ �. Property Line---- . <br /> " . <br /> SEEPAGE PIT [ j Depth__c2r�S..-_Diameter.::.��J_ ____Number____ - _T Yet Rock Filled Yes¢ No ❑ <br /> Water Table Depth_-- ! / '' <br /> -lao'-------------------a = ------_.Rock SiSizer.= -------` -s <br /> Distance to nearest: Well---___/ _________________ _____ -- Line.._._________-_._______ <br /> Date --;--.-- ) w <br /> REPAIR/ADDITION (Prev. Sanitation Permit#__--__---.--.____--__.__._._ -" <br /> Septic Tank (Specify Requirements)---------------- <br /> DisposalField (Specify Requirements)-------------- ------- ------------------------------------------------------- ----------------------------------------------------------------------- <br /> -----•----------------•- --_------------ ------------------------------------------------------------------- -----------------------•------------------------------------------------------------ ------ -------- <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 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 /> to become subject to Workman's Compensation laws of California." <br /> Signed------------- ----- ---- -- ------ -- ---- ---------------------------------- -----Owner <br /> By------------_----- ---- - ----- -------- -- ---- -- -----.Title-----DW-....._..._6V - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- DATE. <br /> DIVISIONOF LAND NUMBER--------------- ----------- ------------------------------------------------------ -------------------DATE.-------------------=--------------------------- <br /> ADDITIONALCOMMENTS------_---_------------- ---------------------------------------------------------------------- -------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------•--------------------------- ------------------------------------------ ---------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ --------------------- <br /> -- ------ - ---------------------------------- -- --------------------------------------------------- ------------------------ ------------- f <br /> - --------------- <br /> Final Inspection by:---------------------- Date.. <br /> EH 13 24 SA JO QUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />