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FOR OFFICE USE: ri FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT frNR% <br /> f{1ti' S <br /> i {Complete in Triplicate} Permit No-71-74$7q <br /> t Date <br /> ................................................. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the Son 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 /> �Z._S'`7?5'� ..' � ,q; .e,•...�..:..�. . ,,� t � fes ) <br /> JOB ADDRESS/LOCATIONr .. 'Yl... .......... <br /> ..................................._...-__.CENSUS TRACT._ 04 y <br /> ^O <br /> Owner's Name.._. ...._ ................Phony..." .YX <br /> .. . ...... . .... ...... ......... . . ._. . . ......... . <br /> Address.... '. f..-. ��...._........._._.......... - ........... .....City Zip. ..i�yoZ. ........ <br /> Contractor's Name._ G'�! � .._. '.... O� �Cf ......... ..................License #.�.�� 3. Phone. " F4.7........ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ <br /> Motel ❑ Other.................... . .•-._- ............. <br /> Number of living units:....... ........Number of bedrooms......... _Garbage Grinder............ Size.............. .................. <br /> Water Supply: public System and name--..... ....................... .. ................. ••-----._.......-...-_.... <br /> .......................................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ PE at❑ Sandy Loam ❑ Cloy Loamx <br /> Hardpan 1% Aclobeg. 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 TANK Size.Il�X>G'.- --- ••.••••..•----------••••• Liquid Depth._IT....... <br /> Copacity./� ....Type.... ......Materia _6A Gr'.....:No. Compartments...._ -'.........-- ....... <br /> Distance to nearest: Well.......) ._• '-.... _..._--_-....Foundation......4-0. .t".. . Prop. Line... .-..._.___.__---•- <br /> LEACHING LINE No. of Lines <br /> r <br /> . .. Length.....----•--••---._.. of each line...l.�.... ..............Total length .. ;91(:-;w......... ............... <br /> 'D' Box... ..Type Filter Material__ ...Depth Filter Material_...ki ....... ...... ........................... ......... <br /> Distance to nearest: Well....... Foundation...... o ...........Property Line ............. <br /> SEEPAGE PIT [ ] Depth.......... .....Diameter.......... .. ......Number................ ............ Rock Filled Yes ❑ No❑ <br /> Water Table Depth............................... .. ..........----•.......Rock Size. ......... ................ _ ..........--- -- <br /> Distance to nearest: Well...................................___.Foundation................ _. ......Prop. Line............ .._..---•---.- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....._............................ ..._.........Date..................._..........._.. ........ <br /> Septic Tank (Specify Requirements)...... ... ........ ... . ••••.• ........ <br /> Disposal Field (Specify Requirements). ...................: ..............--................_............................... <br /> ........................................................ ...... ........•--•---•--........-_......................-_,.....,........._......------ -._............. ....................................... <br /> .......-----•--.........................•--._....._.. --------- -------------- ­­................. •------ .......................... ............ ,y............_...... - <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.......... .. Owner <br /> By........ ................................._---.___ Title.__.. ....................................... <br /> (if other than owner) <br /> FOR DEPART ENT USE ONLY _ <br /> APPLICATION ACCEPTED BY........ .. h. .... . .. ..... . ...::..................._--------. DATE. .. ............ <br /> DIVISION OF LAND NUMBER...,,,,......... .. .. .................................DATE............................... ..... _......... <br /> _71TIONAL COMMENTS....... ............... .I................_-- ••••• ........ ........ . <br /> ... .......................................•----- ........---....................................................................................................... ....................... <br /> ................... ......... ...................... ._ -..................................--...... ......__.........-•--• ...••--.....•...............__..............._................._............ <br /> ...................................................... .. ... ...... .. .. .........-...J.....__._........._...........I.............._.._._.... <br /> j...._......_.-._._. ..... _.- ------- <br /> Final Inspection by........... '.. .. ..........................,...Date....• ... .L! ...-......... <br /> FdS 21677 REV. 7/76 3M <br /> EM 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />