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FOR OFFICE USE: V) FOR OFFICE USE: i <br /> APPLICATION FOR SANITATION PERMIT <br /> V Permit <br /> S <br /> {Complete in Triplicate?' / <br /> -------------I--------- <br /> L/ <br /> Date issued.,/D..-.,_,F/- 7 <br /> _."--_-_-___... This Permit Expires 1 Year From Date°lssued <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 Count Ordi nCZl.7 and existing Rules and Regulations: <br /> JOB ADDRESS/ 77 <br /> LOCA N,. ', _ <br /> C - <br /> ENSUS AC p <br /> f Ph I on <br /> --- �'eO�Owner's Named - - - --- -- ---------- ------------- --- ----- <br /> .l` <br /> ! ------------ Cit?'= t:• '� =�- z;p J} <br /> Address.. ------ - <br /> f <br /> Contractor's Name_ 94f .. <br /> ----------- ,f License #. J . 1-_Phone_ <br /> Installation will serve: Residence Apartment HoL e�=❑ Commercial ❑ Trailer Court ❑ t <br /> kr-- -- -------=--- ----- ----- - <br /> 3 units:-___. .__-_ Number of.bed s'.. Garbage Grinder Lot Size.---. _ <br /> Motel � - Other �_ <br /> fc: ... - <br /> Number of living •� / f �, = = <br /> Water Supply: Public System and name------------ -----•------------- ------�------ .-- --------------- ------ :----�----- ----- - - ---------- Private 8� <br /> Y <br /> t- -Character`of soil to a depth of 3 feet; ;;Sand El "Silt❑ Clay.❑ Peat❑ Sandy Loam lay Loam E] <br /> Hardpan= Adober❑ Fill"Materi " <br /> 9l .. If Yes, type =` <br /> (Plot plan, showing size of lot, location of system in relatio`nytow <br /> wells, bui dings,`etc. must be placed on reverse side.) <br /> . <br /> i --� <br /> �+ <br /> NEW INSTALLATION:' <br /> (No septic tank o.6seepage ;pit permitted�if,public sewer is available within 2d0 ee#, <br /> i - _ l J" .. ------ ---------------- <br /> PACKAGE TREATMENT ('] " SEPTIC TANK] Size---' --------------'--:---`---- - Liquid Depth. <br /> I Ca acit TYPe-----'-------"' ---Material-------- ------=---- <br /> __...No. Compartments-.--_.__;------. <br /> I ` _ Fa _ • <br /> ,Distance,to-nlearest.--Well-- line .------- ---- ""�-' - Prop Line_1. .. ' <br /> f <br /> ,�._-�'__.Length"of each un anon Total Length ------ ------------------------ <br /> ------------------ <br /> -------------- - -------;-- <br /> LEACHING LINE: ['] Na of Lines_____--------_ � - " " <br /> �� YP . Depth Filter Material -° --- --- ---- --------------- ------'-- <br /> D' Box..._ F T e Filter Material., <br /> ----- t <br /> - Tspistance to n crest:Well------------------- <br /> I _ --Foundation '"-- ---" --,. - Property Line_------ ------ -- --- -------- <br /> i :x ll Y ❑ N ❑ <br /> s ----- t Rock Filled es o <br /> ' SEEPAGE PIT [ ] Depth .. ...Diameter - .._. Number.._ #""-"" <br /> e". ----- f 1 - ----- E <br /> ` Water Table:Depth ---------------- �--�' '"-- Rock Size. -- --------------+ ------------ <br /> Distance fo nearest: Well--------=------=-----°---------' l ---Foundation__.__..-,--------- Prop. Line _.-- _- - -------" -- - <br /> f t <br /> REPAIR/ADDITION-(Prev:'Sanitation Permit#_! <br /> ---- ---- ------- -------------- ---------•.Date.. ) <br /> Septic Tank (Specify Requirements). ::: I }i = ---------=--- ------ - ----=----------------------- --------------- ----n------------�----:------:-- ----'--- <br /> ' Disposal Field (Specify Requirements);----- { © r ~----��` " 1145'1- ------y `- �e1 <br /> /-� ---- . = . ------ - . ------------------------------------ . --------- <br /> ----- <br /> -- -.. _ <br /> i <br /> ----- _... <br /> --- _ , - -== _ --- _ <br /> (Draw existing `and required addition on reverse side) f <br /> t „tI <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: : w <br /> ` "I eertify that iri'"the performance the work'for which this permit is issued, I shall'not employ any person in such manner as <br /> to becomeisubject to orkma s Compensation: laws of California." <br /> kSigned. {, = ..---,.Title-------; ---: -'Owner <br /> e <br /> (If other than.owner) <br /> - y <br /> ,FOR DEPARTMENT USE ONLY' <br /> k ------ = ----------------DATELU'_-Z-� - <br /> APPLICATION ACCEPTED BY ----- ------------------ <br /> Com__-.-- -. -- _ <br /> DIVISION OF LAND NUMBER -----•-=- ------------ - ---- DATE <br /> ADD_ ITIONAL COMMENTS------------------------ ------------------------------- ` <br /> -------------------=---------=----:-------- --- . --- ------------------------------- <br /> ------------- -----------_------------------------- -------------- -------------- ----------------------- <br /> -- <br /> -- -------------------------- <br /> -- ----- -- ----- ------ <br /> - - - - ------------- <br /> - : D t ------- <br /> Final -- <br /> �lns ection•b _..^.� . �•'. r" - -----= ate -- ------ � - ----- --- <br /> i <br /> p Y,W <br /> - --- ----------------- ---------------------- -- <br /> k <br /> EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M <br />