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FOR OFFICE USE: FOR OFFICE USE: <br /> - �APPUCATION FOR SANITATION PERMIT � <br /> ... .... (Complete in Triplicate) <br /> Permit o.....79.-'...._S3.7 <br /> Date <br /> �__......- <br /> ----------- ------- ..____ This Permit Expires 1 Year From Date Issued <br /> 4pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> `chis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: /J <br /> JOB ADDRESS/LOC N....�IOd�------- CENSUS TRACT.- 0 <br /> Owner's Name �?�� - - -------- G.IO----- -------------------------- one---o <br /> Address._--- - -- - •2--/--/-- --�i-- -------- - -------------- - Ci _ - Zi <br /> Contractor's Name._v,G.CrCL�.. License #3 .45? ----Phone---- <br /> -Installation will serve: Residence j]i Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> . Motel ❑ Other---------- ------- ------- ---------- ...... <br /> i <br /> Number of living units:..../_.-....Number of bedrooms-_3__.Garbage Grinder -- -- - - Lot Size._4�.�_ _Z.. <br /> -Nater Supply: Public System and name ---- ------- - --------- - - ----- ------- -- ------------------------------------------Private, <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material------------ 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> -PACKAGE TREATMENT [ ) SEPTIC TANK 010] Size._---5''XS',x.-9Y..,; _--------Liquid Depth.----S- --------- <br /> Capacity 1ZVr a-----TYpe-f`` --------Material----i.DAt- - ---No. Compartments-- '------- <br /> Distanceto\nearest: Well_1_LO- ----------------------Foundation -------------Prop. LineJQo <br /> LEACHING LINE No. of Lines._N-3_------___.._.Length of each line_..--_VV.1.---...___Total <br /> Length ......440of-.___..-..-...._ <br /> 'D' Box. ... .Type Filter Material_l`rtr��t_Depth Filter Material._-_o2_!--------------------------_.._-__.._'____ C <br /> Distance to nearest: Well----Ido..--..-.---.Foundation-_._���---------_-_Property Line...5z _ ----- ----------it <br /> SEEPAGE PIT DepthrpZ5.7..----Diameter ------Number-------------3.___--------- Rock Filled Yes45? No [] <br /> N — /� ii---------------- <br /> _ Water Table Depth--------- - ---------------.a:-•-.-----.------.Rock Size--------.- <br /> Distance to nearest: WeIL_-. --------Prop, Line --------------- <br /> ---------------- <br /> ` REPAIR/ADDITION (Prev. Sanitation Permit# ------------ -----------,. :_-_--_--__.-:__-..Date-..._-.._-_--.. - <br /> 66eptic Tank (Specify Requirements) ------------------ <br /> ------ \------------ <br /> Disposal Field (Specify Requirements)------ ------------- ----------------------------------------------------------- ------------------------------------------------ <br /> - <br /> --------------------------------------------------------------------- <br /> --....--,----------------------------- <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, 1 shall not employ any person in such manner as <br /> to become subject to Workm n's Compensation laws of California." <br /> Signed-- -- ----- - - - Owner <br /> .BY - 4 - '--own <br /> --- ----------------- ... -- Title---&C k� -------- i� <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> b"APPLICATION ACCEPTED BY--- - .- .- - --------------_._ _---------------DATE . <br /> DIVISION OF LAND NUMBER.-- ---- ------ - - --------- --- .---------- DATE.------ - ----- <br /> ADDITIONALCOMMENTS-------------- ------------------------------------ ------------------- -------------------------- ------------ <br /> - ------------------ ------------------------------------ ---------- --------- <br /> -- ---------------------- -------------- ---------------- --- <br /> Final Inspection by:.�- .. ------------ --------------- -------------------Date_-r'�.- 'l_ 9--- ----------.. <br /> `EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fb3 21677 REV.7/76 3M <br />