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rOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �j <br /> (Complete in Triplicate) Permit No.._.7d <br /> ------------------------------------------------- <br /> dp <br /> Date Issued..�..�/. _"_7. <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 Ordinance No. 549 and existing Rules and Regulations: <br /> n� ---------CENSUS TRACT ADDRESS/LOCATION-- 7_ �'`�'�--• // <br /> Owner's Name ----- ---- ------ -- --- --- -—----------------------------------- ------------Phone--_'.q,6�0.-__07/f------- <br /> Address--- V --c_t ---------------City---- ---------- ------ -----Zip-----1­--------------------- <br /> Contractor's Name----------------------------- � ----------------.--License #.,ZSLH-�'J_.....Phone__7_41_7'n 7 <br /> Installation will serve: ResidenceApartment House.❑ Commercial [-] Trailer Court ❑ <br /> otel ❑ Other---- ----------------------------------------- <br /> Number of living units:-------f ------Number of bedrooms-.--F---.Garbage Grinder-------- ---Lot Size----- ------------------------ 'S <br /> WaterSupply: Public System and..name------------------------ ------------------------------------ ---------------------------------------------------------------------PrivateA <br /> c <br /> Character of soil to a depth of 34eet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Adobe Fill Material------------If yes,type________________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,iefc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is,,dvailable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK �'] Siize____.5___X__ -----------__-------_------------------Liquid Depth_._Capacity 5____---____--.______ <br /> --------TYP e---� "�---- Material--- --- -;-No. Compartments--------- <br /> 1 <br /> Distance to nearest: Well---------G _________________________Foundation._:_____l0-------------Prop. Line!r --------- --------- <br /> LEACHING LINE ] No. of Lines..__----�----------------Length of each line._--.-_.�,;:---_.-_.-__-Total Length.-_._lam.____._.--____.--.____.___ <br /> q� tr <br /> 'D' Box....�� a Filter Material__-Depth Filter Material------------/tT_______________________ <br /> Distance to nearest: Well---1_0.0_-r----___-_-_.Foundation.._-_- P-__f-!-___--.-_Property Line_.....�___________________________ <br /> SEEPAGE PIT [ Depth.. .___Diameter--___-.3.3.____..Number______._. '_...___ Rock Filled Yes No E]th----- -----------------�---�------------------------Rock' Size. <br /> Water Table Depth �<X <br /> Distance to nearest: Well---------- _______________________Foundation__--------- Prop. Line---7.�-_-t_-____---.___. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date____-.--.____._._ ------------------- ) <br /> Septic Tank (Specify Requirements)--------------------------- -------------------=-------------------- - ` ===_ ---------------------------------------------------------- <br /> Disposal Field (Specify Requirements)---------------- ----- ------------------------------------------- <br /> i `.. <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-------- ---- ---li <br /> --------- . -- Owner <br /> BY--------------- <br /> Title_.____- r <br /> ------ --------------------------------- <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE. <br /> --------------- <br /> DIVISION OF LAND NUMBER.. DATE. <br /> ADDITIONAL COMMENTS----------------------------------- ----- <br /> -------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------- ------------ ------------------------ <br /> ---------------------------------- ----------- <br /> STRICT <br /> ---- <br /> Final Inspection b --- ---------- ate.---- -i <br /> - --- ---------- <br /> EH 13 24 SAN JOAQUIN L C EALT DIF&5 21677 REV. 7/76 3N <br />