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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - - - - - -- - Permit No---- <br /> ---------------------------- <br /> ........ <br /> o.--- 7 -7� <br /> - ---------------------------- (Complete in Triplicate) <br /> --....---------- AF-77 <br /> Date Issued...{=- <br /> - ----____-__------------------ ---- ------ This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Loc/a�/l��Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County once No.549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 7Q / ...._ ..CEN US TRACT------------------ <br /> Owner's Nome _ <br /> .. ------------ <br /> r-- - - - _ ------- Phone----- s --------/--�----------- <br /> Zip.....C -----..--------------------------------------- ---- - ------ <br /> Address.---------43-0------ --- <br /> Contractor's Name-.-.�. -- - � LF" -License #- -�1�----Phone--- <br /> 111 - <br /> Installation will serve: Residence Apartment House❑ Commercial E] Trailer Court C]otel ❑ Other----------- --- --- <br /> -- -- - / y / <br /> Number-of living units:--- -/- -._.Number of bedrooms----- ----Garbo a Grinder.. . .-Lot Size_-40, _`. - ------------------------- <br /> Water <br /> ------- --------------- <br /> Water Supply: Public System and name---------------------- - -- - -------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Cla ❑ 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, 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 <br /> tnrTANK [ ]_, �� Size_ [..X.,% --f P------------------_----Liquid Depth_...- --------.- _ J <br /> Capacity -�hQO---Type-_14 -.Material--eWLT 'l----------N4+. ComportrY\ents ,g_ ------------'------ 0 <br /> Distance to nearest: Well---.- -------- -----Foundation----.--_---..---_---.-.Prop. Line-.....----------- S <br /> LEACHING LINE [ ] No. of Lines_..----.--.-._-------.Length of each line_--%--�--OlTotal Length.-._--._-�Q..._.-__.-C <br /> 'D' Box---- Type Filter Material__..—Depth Filter Material--------/-T_------__._-------------------------------9 <br /> Distanceto nearest: Well_.__-----.-__..__._. oundation-------_-------------...-_.Property Line----__.----------._- ........... <br /> SEEPAGE PIT [ ] Depth._;Z_$:7_-Diameter-.... - Number__.-�----------------- Rock Filled YesA No 7 <br /> ❑_ <br /> Water Table Depth----------- -----------------------------------------Rock Size------- -..f - <br /> Distance to nearest: Well-__------..---_-.---------.__---.---.Foundation----_-..--- - Line- .._-._..._. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-----_--------------------------------------------Date----------------------------------------------) 7 <br /> SepticTank (Specify Requirements)----- -.....- ----------------------------•-......................-------------------- -------------'-------------------...-------------.__.---- <br /> Disposal Field (Specify Requirements)------------ --- - -----`------- "- --------- ---'----------------------'-----------------------------. <br /> -------------------- ----------------------------- - -- - ----- ------ - - <br /> - ---------- -- ----------- - <br /> .- ------------------------- -- -----------------------------: ------------------------------------------------ - --------- . ..... - -------- -- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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--- ------ <br /> . ------------ ----Owner <br /> By- -- ' ' ---- ---- '- 77 - -- -- Title - ---------------------------------------- <br /> ;&r <br /> -------------- <br /> f�er than own <br /> FOR D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- - -- - --- -- ----- ------------------------------------------_.. ---------DATE � <br /> DIVISION OF LAND NUMBER.-- ---- ----- -- --- -----------. -. I------------------------------ '---------DATE-------------------- ----------_--'------ <br /> ADDITIONALCOMMENTS-- ------ -------- - - -- - ------------------------ -_.'-" ',S`' --------------------------------------------------------------------" -' -------------- <br /> --------------------------------1------- ----------'------------------------ <br /> --------------------- --------------- -------------------------------------------------------- ---------------------------­---------------------------------------------------------------- <br /> ..'-----------------__""""-------' -- ------------- -- <br /> --------- ------ . <br /> - "- --.. -- <br /> --'� �' ' ----------- <br /> Final Inspection by:-- ... ------------------ - Date - _-----------------'J..- - <br /> ` of 13 24 "" SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV.7/76 3M <br />