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FOR OFFICE USE: FOR OFFICE USE: t. <br /> APPLICATION FOR SANITATION PERMIT <br /> /! 0 <br /> (Complete in Triplicate) Permit No. _.......-.- <br /> Date Issued./.;.L <br />( - This Permit Expires 1 Year From Date Issued <br />€k Application is hereby mode to.the SonjJoaquin 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 /> I JOB <br /> I AW DDRESS/LOCA+T4,ION0. -,_�,{.,1.- !.-;-..s.... .�. ../..-.�._y.� <br /> ....... _---------------- <br /> \= - ------- ----..CENSUS TRACT..----- ----- .... .....-.--- <br /> er's Name..Own <br /> - <br /> r <br /> ,��.. . .. ..�p C ...............E <br /> ----. ............... <br /> ... ..`..P.hone.. <br /> �.`.. <br /> ....._...... <br /> .v - -Address.----- city ziP <br /> ontractor's"Nzme2.. ---------- <br /> ------ ....... - � ...--�--- - -...License #- -...---...-----......_-Phone.......:....- -_..----- <br /> ..-........ <br /> Installation wiIF.serve: Residence DK Apartment House ❑ Commercial .[] Trailer Court ❑ <br /> Motel ❑ Other..... ------ <br /> Number of living units:._ „ _.�-.Number of bedrooms..._ _.Garbage Grinder__�e.S-..Lot Size-----_...._I� <br /> Water Supply: Public System and name. fiPrivate l] <br /> - f <br /> Character of soil to a depth of feet:" Sand Silt Cla <br /> P ❑ ❑ yPeat ❑„ RSandy.Loam Clay Loam ❑� <br /> _ �. — <br /> Hardpan ❑ )Adobe ❑ Fill Material ------ <br /> ---.lf yes, tYPe-------------------- ----- ... '� <br /> (Plot plan, showing size of lot, location!of system in relation to wells, buildings, etc. must be placed on'reve•rse side.) <br /> NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK a Liquid Depth.-...:-_-----_......... <br /> . <br /> Size-- . ... ......... <br /> Material.. ?- 1'- . No. Compartments-............... <br /> Capacity..���.v--- Type -fec - 77 ------ <br /> Distance to nearest.Well---0V .�"(1Q. '7....... :........Fou,;dation.. Ia.. �irProp, Line... <br /> LEACHING LINE [ ]"" No. of Lines ._ ..-_-------------Length of each lma...3 -...X_30------ Total Length <br /> YTYPe Filter-Material.... <br /> Depth Filter Material...._. ...... . ...............D' Box__ !bL <br /> IA <br /> Distance to nearest: Well.�ll�r:.1Q. - Foundation_. g .::........_Property Line....4--1 .......... <br /> -SEEPAGE PIT ( ] Depth'. k....: __I_Diameter--------------......:Number---..---------re---.----------. f r� Rnck Filled Yes ❑ No <br /> Water`Table Depth-------------I—'.............. Rack Size'.- ... <br /> 1�, t # . <br /> Distance to nearest; Well_._:_--------L............................Foundation.....r..... Prop. Line-------...--------.--.---.- <br /> 1 y Date__... V r µ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.:.--..-----:•-•...................�:� -.. .....-....-----------"----------_--.) <br /> Septic Tank (Specify Requirements) ;; :" --- - --------- <br /> Disposal Field (Specify Requirements)Mr'.--.-------------- <br /> .-_ --------- ----------- -- ------------------------------------ <br /> ------•------ ---- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certifyr,tha't-I'°hlave prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules a'nd Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: 1 11 <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 l <br /> to becomes ect to Workman's Co ensation laws of California." <br /> Signed-- /J��.... _Owner i <br /> - r <br /> BY ----------- -------------_---- -- ........ - ------ Title.--. ---- - <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY......... r'.f.. .-- ------------- ----------------- ----•---------------- .DATE ..... .205 -------_-- <br /> DIVISION OF LAND NUMBER---------...... .l. DATE__.... . . ........ <br /> ADDITIONAL COMMENTS.. ::•- ........ --..... -..- <br /> -----;--•------------- :------- .. --..........--.... ....:.. ..------_ -- ......------.-----.....-•----........----- .... ---------------------- <br /> ----------------:...... <br /> -----------------------------------•----... <br /> ____------ <br /> Final Inspection by:....... . �- ... ----------------------- -- ........... ----- ----- ---.......Date ----------- --- ... ..... <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 t 7/76 3M <br /> - % <br />