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f <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE:, <br /> -- -- Pe mf it-N,o.-l-- ?130 <br /> (Complete in Triplicate} f�/1 <br /> --------------_---"-__."----------------------------- `r� `+'� <br /> JDate Issued.`t..".P. .___.___ <br /> i ---------------------------------------------.. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a perrn-if to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rutes and Regulations: G <br /> --- - - ---'�-�- ----.. TRACT ---- - -- -------------- <br /> JOB ADDRESS/LOCATION._...., _I ------��------- - ------- --- �`:._ CENSUS -- <br /> t <br /> ' t fs . <br /> I Owner's Name_.. ---�����'-----.- �_� - - ------- - ------ --------- -------- --- <br /> Phone <br /> Phone_- <br /> - <br /> ---- -----:---- <br /> _ZiAddress------- <br /> _� CPhone Contractors Name--- <br /> F <br /> . r <br /> Installation will serve: �_[Residence OS-Apartment House ❑ Commercialo Trailer Court ❑ <br /> Motel ❑ Other----------------------- --------------------- <br /> t - , i <br /> Number of living units------------ __%Number of bedrooms.--_--_-"-."Garbage Grinder------------Lot Size".- ---60------------------------------- - <br /> Water Supply: Public System and-name-,.--------- ------------------=-------------------`--------- --------------------------- ----------------- -- rive <br /> Character of'soil to a de-th of 3"feet; Sand r] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ :Clay Loam <br /> v <br /> I <br /> dr-pan ------------------------ <br /> d ; Adobe❑ Fill Material__.-________I€yes, type_.._._____"__________________ __ t <br /> (Plot plan, showing size of-lot, location of system in relation to wells, buildings, etc. must be placed;n reverse side.) <br /> NEW INSTALLATION: 1 No' septic tank or'seepage pit permitted if public sewer isavailable within••200 feet,] - - , <br /> t 1 ,--- - �- <br /> PACKAGE TREATMENT '[ ] -SEPTIC TANK' [ ] _� T Size__` '�_��--"""""" liquid Depth.---:.>,,V_____" . ____ <br /> -Jz0dr�sn - . Capacity — - TYPe J� �'-� Material No. Compartments <br /> -kAl ���Y'�?9 rl70 <br /> Distance to nearest: WeIL- :-_ - _ ..._Foundation �i_ "._"_ ___,__..Prop. Line. _ <br /> LEACHING bNE-1 [.] ] No. of Lines.- _..:__.:_` ength, of each lino.__,."" _.- -.__;____Total Length ./" -------------- <br /> 'D' <br /> ------------'D' Box ' __.__....T a Filter Mate ----------------------------- <br /> 'to <br /> _ <br /> Type - tial��+C�,'�.Depth Filter Material .__�l' __ ______ ____."_ _ _.-._-- -- . <br /> ------- --- - i _ <br /> R _ =7- <br /> Distance to nearest Well Foundation '-"""" Property Cine._ i ' .____ <br /> r :] <br /> SEEPAGE PIT:r [ ].,r :Depth i? ____Diameter..; �7--._:._._Number-- _ ____________ _____: Rock Filed Yes [ No ❑ <br /> 3 a Water Table Depth----------------------------------------------------------R.ock Size_.--------------------- ----------------------- <br /> Distanceao nearest:,Well-_- --------------------Foundation----------------------------Prop. Line------------------------------ <br /> ... � - � , <br /> REPAIR/ADDITION ]P7ev:Sanitation Permit#--------- =-------- <br /> Date •�..�..1- <br /> i Septic TanVSpecify Requirements)---- ------- -" ----------- ----------------- <br /> - ---------------------- -- - <br /> �. ---------------------------------' ` ---- --- --- ----------- <br /> Disposal.Field (Specify Re�quir_ements)-------------�------= - --- =---= '-- ------� ,----- <br /> -- --_ - - - _ _ -------- <br /> ----------------- <br /> ----------------------- _ . <br /> ,m��� <br /> '------------- ---- - ----------- -----------=------------------------------------------------------ -- ----------:---------------------------;------, _----------- <br /> (Draw existing and required addition`on reverse side) i a <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 Sari Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: . I I <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 /> G� . <br /> to become subject t man's ensation laws of California." ' #' <br /> Signed .. t-- . --------------- -------Owner - r <br /> i <br /> " . Title =--- - ------------------ --------------------------- --- --------- <br /> BY-=----- --------------------------- --------- ------------ -------- --- --- ---- <br /> (If other than owner] l <br /> F05 DEPARTMENT'USE ONLY <br /> i APPLICATION ACCEPTED BY.. -------------------------------------------- <br /> --- ----------------------- <br /> 1--­i <br /> DIVISIONOF LAND NUMBER-------- - ---- -- ------------- --------- DATE------------------------------------------------- <br /> ADDITIONAL <br /> Z -- --- z <br /> - <br /> ADDITIONALCOMMENTS------------ -- ------------------------------------------------------- ------------------------------- :----------------- -- - ----------------- -- ----- --- <br /> -------------------------- -- -------- <br /> # _[ <br /> t ------- - ------- --------- ------- ---- - -- T <br /> k <br /> ------------ ------ -------- <br /> c <br /> w r , A: <br /> ------------- <br /> r� <br /> za, ,. -- - ----- �t ------ - ------------ <br /> EH <br /> -----� 'Date- l� � } <br /> Final��Inspection by.-- --- -""-- -"""--. ---- --"""--- - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r F&S 21'677 REV. 7/76 3M <br />