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-� FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- . . Permit No.7F'_7�3- <br /> (Complete in Triplicate}- , <br /> -------------------------------- ---------------- --- ��`• Date issued__S`- <br /> _.--------------------- This Permit Expires 1 Year From Date Issued <br /> � I <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. 549 and existing Rules and Regulations, <br /> ��---�---- ---- . <br /> CENSUSTR <br /> JOB ADDRESS/LOCATION.., - <br /> Owner's Name-:----- -- ----- �- ------ =--------------- ----- ---------- -------------- - ------- <br /> Phone <br /> Addres — - ------ ------------- --- -- City . zip '� --------------- <br /> ------ <br /> r ( x - <br /> Contractor's Name : --------------- ------License #.__ .�_?-Z/ Phone-. - <br /> Installation.will serve: ; Residence E��pa4hent House ❑ ;Commercial l] Trailer Court ❑ <br /> Motel ❑ . Other---==------------ ------=--------------------- <br /> Number of living units:_-./_---.--Number of bedrooms--5 --Garbage Grinder__.--.` ot.Size_.,-_. d-------------- ------------ --- <br /> Water Supply: Public System and"name-----------------------=--------- ---------_------ --- --- _--- ------------ ----- ---------------------- --------------- Private <br /> • f� <br /> Character of soil to a depth of 3 feet: Sand El5_ilt❑ Clay�� Peat ❑ Sandy Loam Ll Clay' Loom ❑ <br /> Hardpan ❑ Adobe ❑ Fill Mdfierial----- ------If Yes, type---------------------------------- Q <br /> i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) L <br /> NEW INSTALLATION: - (No septic tank `or seepage pit permitted if public sewer is available within 200 feet,) r/ } <br /> J Li uid De th, - 2,/ <br /> PACKAGE TREATMENT '[ ] SEPTIC TANK �'�� � . Size___�,_�--. --!`-'-----�,1- :---�--: -- q P -- <br /> Capacity_ - TYPe----- 1` ''f --Material = dd -No. Compartments---- 2- <br /> Distance to nearest: Well- ---/� ---- ----------•­ ------Foundation------I-c�: c Prop. Line <br /> LEACHING LINE Na. of Lines------- -- Length af_each line--------- --- -__-__._ -- Tatal Length.--. __ _- <br /> ----- <br /> --=-------=-- <br /> J�`� ii /� <br /> D' Box"_._----.---Type Filter Materia �epth Filter Moterial_- ---_ _. -4 /_, <br /> Distance'to nearest: Weil <br /> !-` -/" .Foundation._ ------ =- --.._Property Line.-"C� --- --- ---- <br /> o - . ,_. <br /> SEEPAGE PIT [ Depth �5 '-Diameter 3. ..1 umljer -_-_ Rock Filled Yes'i No ❑ <br /> f/i</� -(1 <br /> Water Table:Depth --------------------------------------R'ock Size---- 4 -ry- P -T <br /> p Foundation--- 54 -/-*----- ---Pro Line- -� <br /> Distance to nearest: Well. - - - <br /> ` Date Y - ` ....T � <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_ --_ )3 <br /> Septic Tank (Specify Requirements}- -- --- --- - -- - - , ------ ---- --- -�-- ----- ----- - <br /> Disposal Field (Specify Requirements f ----------------- ------------------------------- <br /> '------------------ -- •- '- } L <br /> [ ----- _ --.- --------------- <br /> - <br /> ----------- - <br /> ------------------ ---- -- ---- <br /> y / --- -------- ---------------- <br /> ------------------------- ------------- ---- ---------------- ----------------------- _ „ <br /> 1 y <br /> {Draw existing and required addition on reverse side), <br /> �� \4 <br /> hereby certify that I have prepared this application and-that�the work-will be done-in accordance with San-Joagqin County <br /> Ordinances, State Laws; and Rules and Regulations of-the Sari Joaquin Local"Hl alth District, Home`owner or licensed agents <br /> signature certifies the following: <br /> p � <br /> "I terrify that in 'the perfbrnian f�thefor which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject orkman ompensation laws of-Gallfornia." <br /> I � OW t - <br /> i Signed ----------- -- ----' = <br /> BY • - --- <br /> " -------- --------------------- ...... ----- ,G ---- _ --------------------------- <br /> - , <br /> Title =_� <br /> (If other than owners <br /> ,• 'F FOR*DEPARTMENT USE ONLY' ` <br /> APPLICAT�OFLANDNUMBERR <br /> D. BY �f`-- �-- TE - <br /> DIVISION ----------.------ - -- --= ------------- DATiE <br /> ADDITIONAL TCOMMENTS-------------I----- -------------------------=-------------=------------- <br /> ---------- <br /> -------------- ------------ -------- <br /> - <br /> ------ `------- - -- - -- - <br /> zt - - -------------------------- ------------- <br /> -------------- <br /> ------------------ ---------------- --------- <br /> ----------------------------- ------ <br /> Final <br /> --- <br /> - --- -------- <br /> �-- Date- 7 <br /> Final Ins ection b -�r -_-:_------" <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2177 REV, 7/763M <br />