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`mayFOR OFFICE USE: <br /> OVIFICEIU-S—E. APPLICATION FOR SANITATION P.ERMIT <br /> ----------------------------------------------------------- Permit No------- ------ ------- <br /> (Complete in Triplicate) <br /> ------------------------------------------------ <br /> Date Issued_.._?7� '7 <br /> ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> T&s;agplication,' m de in coQBJ��q� with County Ordinance No, 549 and existing Rules and Regulations: <br /> J <br /> Of"117 V ----------- <br /> DDRE TION------- --- - ---C t- I ------ ---------------- <br /> -Sf/L�c ----- ---- -------- - ;4e---------- ------ ------ CENSUS TRACT.. <br /> Owner's Name.--- Phone-g -3 <br /> C --------------- ----- - ------- ------ ------ ------ <br /> Address-----------------` ------ -------------------:------------------- - --- --------- city-. <br /> -ra-------------------Zip- - ------- <br /> Contractor's Name---------5--t-- <br /> -- -----------------------------------------------------------------------License #------------ --------------Phone---------------------------------- <br /> Installation'-wil-14s5irve.4. t Resideric'el Apartment House.E] Commercial E] Trailer Court E] <br /> Other---------------------------------------------- <br /> ir of living snits: -Nurriber,of bedroom L-7— Grinder.-----------Lot Size._-__------ bedrooms -.----Garbage Grinder------------L 16 - ------------------------------- <br /> J.1water Supply-. Publ ic-Syst6m and name_____.____7 -- <br /> ------ ---------- --------------------------------------------------------- -----------------------------------------Private <br /> Character of soil to a depth of 3 feet: LN --86 Ad:,[] -Silt 0 Clay E] Peat ❑ Sandy Locim,�;I, Clay Loam 0 Qr. <br /> f-2A-do' be.Lj .�' Fill Material-------------If yes, type__________________.---_. <br /> {Plot <br /> ype--------------------------Mot plan, showing size of lot, locati8n of system in relation to wells, bbildings, etc, must be.placed on reverse side.) <br /> 0) <br /> NEW INSTALLATION:- `(No septic tank or s"e-epage'pif p6lim'itted if public sewer is available" within 200 feet,) <br /> Size"------------------------------- - -Liquicl'Depth--------------------------- Z> <br /> PACKAGE TREATMENTI SEPTIC TANK­ ---- --------- <br /> ----- ---- <br /> A C-apacityl-'= `= ' Type =---=----------------Material--------- ------;---------No. Compartments_ `--------------- ------- -------- <br /> ."...Distdnce to-nearest: Well--------------------- ----------------------Foundation----------- ---------Prop. Line ---------------- <br /> No. of Lines..........I-------------- Length f ea h line---z�, <br /> LEACHING LINE, Length --------------------------------------- <br /> D Bo terial-- - _6CX__'_.___Depth Filter M I_ z ---------- <br /> x 6- -----Type Filter Ma <br /> y' <br /> 0 ---------------Property Line_4 ---A---------- <br /> je,bistance to nearest: Well--_/0---f--t.'-_.:'__._Foundation �j <br /> -n-'Depth ------ ---n_._Diam6ter_.._.__`__._:_-.__Number--'I-------------- ------------- Rock Filled Yes ❑ No <br /> SEE,A7'E PIT ❑ <br /> ivWater Table'Deolh------------ --------------------------------------------Rock Size--------------------------------------------------- <br /> -7 <br /> Dis�fa&e t3`n'bbirest: Weil- -------I____'- k---------Foundation--------------------------Prop. Line------------------------- <br /> REPAIR/ADDITION (Prew Sanitation Permit#_J-------------- <br /> -------------- - :____Date------------ -------- <br /> SeRticTankI SpLii :Rerm )--- --------------------------------------------------------------------------- ---------- -------------- -----------------------------fDisposal Feld (Speci y Re uirements).4.........1-1-- ----- -------------------------------- ------------- ------------- -------- -------------------------------------------------------- <br /> ----------------------------------------------- •------------ ­----------- ---------------------------- -------------------------------------------------------------------------------I---.--.-- - ----------- <br /> ---------------------------------------------------------------------------------------- -------- --- -------- --- -- <br /> ------------ -------------------- ---------------------------- -- <br /> existing L _d d ddit" <br /> --- <br /> (Draw 6n quire a ion,on reverse side) <br /> I hereby certify that I hci�ve <br /> prepared this application and that thework will be done in accordance With Son Joaquin County <br /> Ordinances, State Laws, and Rules and Regulatio'ns 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,fo, hich 'this permit is issued, I sliall not employ any person in manner-as <br /> 4 <br /> to beco jest to or anompensatt Is.of� California." <br /> ' <br /> Signed--- <br /> �Owner <br /> -- ---------- ------- 1_�----------------- <br /> tle <br /> ------------------------- -------- ------- -- --------------------- <br /> By------------------------------------------------------- ------------------ ------------- ---- ---- <br /> V-1 <br /> -- <br /> (If other ffianowr�er) <br /> -'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY- ------- ---..-.-DATE ----------- --- -------- <br /> V--------------------------------------------- <br /> DIVISION OF LAND NUMBER.__.____.__.,._Y ----------------DATE- --------- ----------------- --------- -------- <br /> ---- --- ----- ---- -4----------�:-------I--- ------------------------------- <br /> ADDITIONAL COMMENTS--------------------------- j <br /> -- ------ --------- --- ---- --------------------------------------------- ------------------- ----------- ------------------------- <br /> --------------------- ----- ----:-- ---------- ---------- ---- - -;-------------:-:------------------------- -- ----------------------- ------------------:------------------------- ---------- <br /> ------------------------------------ <br /> ----------------------------- ---------------- --- - - --- - --- ------------------------------------ -----------------------------------I-------------------------- <br /> ---------------------------------------------- - ------7---------------------------------------------------------------- ---------------- ------ --------------- ------- <br /> )al-Inspection by:_`._=-- -------- -- ----------------Z;--------- ----------- -------------------------r-- ---------- ------Date ---- ---------- <br /> 4 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&(]o REV, 7/76 3M <br />