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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ......:.. y <br /> -----............ . ............................... <br /> Date Issued4::17:?�... <br /> ••-------•--• ---_-----------.................. ...... This Permit Expires 1 Year From Date Issued !!}y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and insfsmf" work herein describe) <br /> This application is made in compliance with County Ord' nce No. 549 and existing Rules and Reg"uf�fic ss�yrf <br /> JOB ADDRESS/LOCATIO �.���.. ...._ -------- <br /> E '� s -----------CENSUS <br /> llTit, <br /> Owner's ........ --- -- -----------•-----------'-� C+S, f} - ....Phone_. . <br /> - '---� �J•'--' -- ,' <br /> Address._. //SO--- �(�t1 <br /> - .............-..... City -------------------Zip.. ........... ... ...... <br /> Contractor's Name.......... .-. "_ <br /> -' License #.. z8. .2�e..Phone <br /> Installation will serve: Residence Apartment House ❑ Commercia Trailer Court ❑ <br /> Motel ❑ Other....... <br /> Number of living units!..../........Number of bedrooms-3.....Garbage Grinder............Lot Size........ <br /> Water Supply: Public System and name---------------- - ------- -' ' -- ......---"- -- ----------------............_.................... ---.......... ..._ .Private [ <br /> Character of soil to a depth of 3 feet/: Sand ❑ Silt ElClay❑ Peat F1Sandy Loam ❑ Clay Loam Q <br /> Hardpan © Adobe Q Fill Material............If yes, type................................ <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: (No septic tank or seep ge pit permitted ifpublic sewer/er is available within 200 feet,) '�LL <br /> PACKAGE TREATMENT [ ] SEPTIC TANK (� Size..��...t ---._.__...fir.......................Liquid Depth....T........__._.... <br /> Capacity-J;20O.....Type.i 4r-.4oLe Material--- :..No. Compartments.....- ---------- <br /> / Distance to nearest: Well.... <br /> ..........j�' (E ------------....Foundation...._._.. � ..,Prop. Line.... ..--..... <br /> LEACHING LINE [/] No. of Lines........... -----------.Length of each line....... �� /---.......Total Length....../ ------_----- <br /> 'D' Box.../....Type Filter Material.....-�_Z......Depth Filter Material.____.__./".'y.........................------- <br /> .---------- <br /> Distance to nearest: Well---------.1r•.m�...Foundation-----,i,Q�---------Property Line.....5�`-..... <br /> SEEPAGE PIT (� Depth._�-q Diameter_....__d73.....Number--------------0............ Rock Filled Yes o [ <br /> Water Table Depth.............../_4L? ..._--.� .-- <br /> -•----_----Rock Size _'���.---------------- <br /> --- <br /> Distance to nearest: Well-------- /- -*-A--------------- <br /> Foundation......./!_.Prop. Line..__.... ._.s <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.................... ...................... .......Date......._..................__.._._..........._) <br /> Septic Tank (Specify Requirements)-............................................................ ---------------........................... ....... <br /> ......_•----------------- -------- <br /> Disposal Field (Specify Requirements)...............-- -- ------- ------......--"..................................... ....... . -'-•'-'......"-.......................-- ........ <br /> .............I.................................... -......... ......----- ---- ................... ......----------- ............................................................. ------------------._.. <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 Sam Joaquin CouZ <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent <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 a <br /> to become subject to Workman's Compensation laws of California." <br /> Signed ..._.._._._._..-_.---------...----------------- - --"------ ... - - --... Owner _. <br /> By ' ----------.- - _........ - ?.<r-/... e .....�� �✓. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY OO� <br /> APPLICATION ACCEPTED BY.... ..DATE......... _2 .!Y...77/.......... <br /> DIVISION OF LAND NUMBER.................. .............. .. - ..........................DATE....................... ------------------.... <br /> ADDITIONALCOMMENTS....._. ................................................---••----'---- _..................._......... ' -- .._.... <br /> ------"' ----- ---'--------'--- --- ------'--.......-"............. --------------------- ............................................ ..... .. .. .................. .. ---- ..............----........ <br /> ---------------------------------------------------------------------------------- --------- •... . ---....... ---- ' ...... ---- ................ ----- . ----......----" ---"------ <br /> ---'........ .......... ..................................... <br /> ----------' <br /> Final Inspection by:.--" ' - ' -'---- -"-- ._... Date------.Sr- - <br /> Of 13 24 SAN JOAQUIN�. T' F8321677• <br /> LOCA HEALTH DISTRICREV. 7/76 3, <br />