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i <br /> FOR OFFICE Us,� ' R S" FOR OFFICE USE- <br /> ----------- <br /> FOR ANITATION PERMIT <br /> ;----------.- 75/7 <br /> (Complete in Triplicate) Permit , <br /> P P <br /> , f Date Issued--- <br /> ..................I........... <br /> ssued.-_..................I........... _. . __ This Permit Expires 1 Year Brom 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, 5d9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. _d-- D._ .. ,!/UQ�IJ01 4*_- '......................._._.,....CENSUS TRACT.--�......... <br /> .. <br /> Owner's Name..... <br /> Address . ......J.69. G -- -------------- - -------city...................----------------- --Zip- -- - - <br /> Contractor's Name--- ---�5wlcc_. ..211C.C.... ... . -.License #,30s5J..a/-------Phone... 42&.�733_.. <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 /> -.._- <br /> Water Supply: Public System and.name_,...;_,.._-------- --------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Zj-�Iay Loam 0 <br /> Hardpan ❑ Adobe ❑ Fill Material_.....-_.-If yes,type................................ <br /> i <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 [ ] ! Size_----------_ __...............`.'________________________Liquid Depth -----------------------m. <br /> Capacity.......---.. .-.-'.Type------•- --Material..... ........ ...........No. Compartments _._..-..-------- <br /> Distance to nearest:`WeIL--------------------------------_-_____--Foundation---=---------------.------Prop. Line . _______..___._. <br /> LEACHING LINE [ } No. of Lines......... ........... ;.......Length of each line,..........-_-..................Total Length. --..----.__----.-.--------------..-.-- <br /> 'D' Box............Type Filter,Material....................Depth Filter Material .__•-__........_....._j-.-_----------..-.----..------------ <br /> Distance,to nearest: Well!--------------------------Foundation-- ------- _Property Line_____________________...•.......... <br /> SEEPAGE PIT [ ] Depth................Diameter------------------._Number........................__..,,_. Rock Filled Yes ❑ No <br /> f <br /> Water Table Depth---------- ----------------------------- ------------Rock Size............... . . -- .........• ------- <br /> Distance to nearest: Well--------------------------------------------Foundation..,,-,................... Prop, Line..._-_--_-__._-__._ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#............... <br /> •----•-•-•------------•-------------Date------•---'-•---•--•-•--:..._.._....... ) <br /> ........... <br /> Septic Tank (Specify Requirements) --------- <br /> --------------------------�..~....._.. <br /> Disposal Field (Specify Requirements).................. ---------.•--............. ._... .......... <br /> ........ �J .................... -------................................. <br /> . <br /> J , I .. 1-' <br /> --........ ------------ ----------- --------,----............... ---- <br /> --- ------._.--------- -- ... <br /> (Draw existing drid 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 San7oaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: C _l <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any p-erson-in_such manner as <br /> to become subject Work an's Compensation laws of California." <br /> Signed........... .. . ...........- --------.,....... ....................... ... ....Owner <br /> .10� <br /> (If other than owner) <br /> FORJQEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -.............................. DATE �. . <­_­­ -?---------------- <br /> DIVISION <br /> . ---.DIVISION OF LAND NUMBER-------------------- - -- ........................DATE ....--.--.---......._.-- -- -- <br /> ADDITIONAL COMMENTS_____________________ _ <br /> ............................... .•---•---••----•-•......_.--.........__. ... ........................ ..,_-----------•-••---------- <br /> • ................... ........................................ .............................................................. --------------•----•-•••- ------------:........................... <br /> .................................. -... <br /> ._ J- ---------- -• --------•- <br /> - <br /> ' ?Final Inspection b ...................................... Date--------- --� _ _ - ---------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F65 21677 REV.7176 3M <br />