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zt <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------- ........ <br /> (Complete in Triplicate) No... . -.-.. ....2...72 <br /> V Permit <br /> ------­------------------ ------------------------ <br /> i Date lssued_44r�1?7.7c� <br /> ............................­­.......I.......... This Permit Expiris,I Year From Date Issued 4. <br /> Application is hereby made to.tRe Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in coni"pliance with County Ordinance WNo. 9 and existing Rules and Regulations: <br /> JOB ADDRESS/LO AT 10t ....... <br /> ------------------------------CENSUS TRACT................... .......... <br /> Owner's Name... ----------------------------------- ...........------Phone...-----------:--- <br /> Address_---- -- <br /> - -------I--------------- ------------------------ ----- --- City-------------------­............. ...........Zl1p..................... . ...... <br /> Contractor'sName..'­ <br /> ......... .. --- License ---.Phone_.. <br /> .3/ <br /> Installation will serve: Residence E] Apartment House E] Commercial 0 Trailer Court El <br /> Motel f-] Other... ------ --- -- ---------- <br /> Number of living units:------ -Number of bedrooms".�' ---...Garbage Grinder--- --------Lot Size_wx..t.,�49_. <br /> Water Supply: Public System anll name....... -------I------- --=` --- __............................. Private El <br /> Character of soil to a depth of,3 i1eet. Sand Silt E] Clay E] Peat E] Sandy Loom [] Clay Loam E] <br /> Hard_dh EAcobe < <br /> ., Fill Material.. .... ....If yes, type.......... .........'_.._...- <br /> P <br /> (Plot plan, showing size of lot; lid cation of system in relation to well s,'b6illdingsl etc.:must be placed on reverse side.) <br /> (N e <br /> NEW INSTALLATION: 0 septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT. I :SE:PTIC TANK I I Size.....------ ---------------------•---------...------ Liquid Depth.-'---"--.-............ <br /> ......Typ' e-------------------...-Material----------_..............LNo. Compartments`----- <br /> . ----------- ----------------- <br /> 4�. <br /> Distclnc� to nearest; Well----------- ....Foun.dati-on............ ----- _ ---Prop,"Line............ <br /> 1 11, All" <br /> LEACHING LINE No. of Lines.._..- ----------------- Length of each line.-------------------------.._,Total Length .. :.._..--......--...._--_-_------•-- <br /> D' <br /> ....... ............D' Boxil__.'....Type Filter Material. - -- <br /> ­­­ Depth'F,ilter Material-----.....-------.-..........____.........-..--- ----- ------ <br /> Distances to nearest:; -__Foundation.--.-__-- ----------,.-,, Property Line_-...----._.--.-.................._. <br /> SEEPAGE PITDepth. ------------------ <br /> .Number__- ----------------------------- Rock Filled Yes F) No 0 <br /> 'c <br /> Watefr able Depth---------------------------------------.............. Rock Size.- -----------------------7......... <br /> Distance to nearest. W'e`II---------------_---------- ----------------Foundation--------- -.Prop. Line.._..._..._..._._........... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------- ...... . .........Date--_-------------------------4------------------ <br /> Septic Tank (Specify <br /> Requiremens)..... . .......I. ... ................. ----------- n�... ...-..11...7. <br /> Y <br /> ...........-.-.-.-.-.Disposal Field (Specify Requirenents) ----- -------------------------- ------------ - <br /> ------- --- ---- <br /> . --- ---- ---------------- .................. k <br /> (Draw existing and required addition on reverse side) <br /> ; w <br /> I hereby certify that I have prepared this appiliation and that the work\�will be done in accordanceith San Joaquin County { <br /> Ordinances, State Laws, and R' ules and ReglUlations-of-the -Sam Joaquin Local,Health,District.-.H6-me owner or licensed agents <br /> signature certifies the foil :1 <br /> "I certify that in the performa ce of the work for which this permit is issued, I shall not employ any pers;n in such manner as <br /> to become subject to Workman's COompensation,Jows of California." <br /> Signed....---- 110... ................ ........ ------------ -...Ownew <br /> By... . .lop . . ...............Title.-- ---- -------------------------- - ---- <br /> other',,than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By,---1.1........ :------------ -•--------...DATE ....?7477 7 ------------- ------ <br /> I <br /> DIVISION OF LAND NUMBERT---- ------­­­.. ­--- ----------- --------­-----­----- ........ ---------------•--------...---..DATE.----------------- ........... <br /> ADDITIONALCOMMENTS__'... . ............... ---------------------- ....... ...... ......... -------------------------------------------------------------­­---­........I---- ...­ . <br /> .............................................. ......­.......­-----------------__­.......... ---------------- ---------------------------__­­----------------------- - --------------------- <br /> --------------- ------- <br /> ---------------------------------------------- ----------- ---- ------------------------------------------------------------------------------------------------------------11------------ ---------- --- ---------- <br /> ------------------:---------------------------1 - -------------------------------------------------------------------L---------------------------------- <br /> Final,lnsp6ction by: ------Date ­ <br /> ---------------- --------------- .......­---- --------------------------- <br /> EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/76 3M <br />