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---'M <br /> I 'D <br /> FOR OFFICE USE. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------------------------- <br /> (Complete in Triplicate) Permit <br /> --------------------------------------------------------- Date Issued--e`5a <br /> --------------------------------------------------------- This Permit Expires I Year From Datelssued <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 /> .TRACT --- ------ ------ <br /> JOB ADDRESS/LOC 11011N------- -------- ----- ----------- -------------------------CENSUS TRA <br /> Owner's Name_----- ------- ----------- --------------- --- --- ----------------Phone__ - <br /> -----City_ -5 <br /> ---------------- --- ---------- - --- -- ----- ------ ---------------- 4,--r'l-- -------------------- <br /> Address- ZiP <br /> - <br /> Contractor's Name-------i�_ �------ - - ------- ----- --------- ------ -------------License Phone-- ---- --------------------------- <br /> Installation will serve: Residence Apartment House.D Commercial E] Trailer Court [I <br /> Motel F1 Other----_ _----------------------- ---------- <br /> Number of living units:__ __ -------Number of bedrooms;--5----Garba'g eGrinder------------Lot Size_ _-__________ __ ___ _________ _______ --------------- <br /> Water Supply: Public System and name---- --- ---- ------ ----------------------------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt E] Clay �Peat E] Sandy Loam F-1 Clay Loam ❑ <br /> Hardpan ❑ Adobe EJ Fill Material_.. _-_ yes, type_-.____ _ __-__-__-_____ _. __ <br /> (Plot <br /> ype-------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACK!!! MEN SEPTIC TANK 4- Size----------------Z� =,::7---------------------------------Liquid Depth-------- ----------------- <br /> J, <br /> Capacity--- -----------Type--------- <br /> _____..MateriaI--------------------------No. Compartments_-------------------------------- <br /> Distance to nearest: Well___ ________________ __Foundation ---------------Prop. Line__ ____-_________ <br /> LEACHING <br /> ine------------------LEACHING LINE I No. of Lines-.------ tth of'64 ------------------------.--.-..Total Length.-_- -------__--------- <br /> --Type Filter Material--------------------Depth Filter Material--- ------------- ------------- ------------ --------- <br /> ­DftftWKWto nearest: Well------ --------- -- -Foundation.-----------------------:----Property Line-----------­------- -------------- <br /> SEEPAGE PIT' Depth------ - -------Diameter_ ----_.-----------Number---__-- Yes N <br /> N--" P <br /> WaterTable Depth--------------- ---------------------:__--------- ---------------- --------------------------- <br /> Distance to nearest: Well__._------I------------ ------- -----------Foundati6k-__,,,___�-------------- --PI�Qp. Line.--------------------------- <br /> REPAIR/ADDITION (Prev.-Sanitation Permit#-.-------- ----------------- ........Date---------------------------------------------- <br /> Septic Tank (Specify Requirements)-------------------------- X------ <br /> ------ <br /> ------------------------------------ -------- ­---------- <br /> - - ------------- -- ----- <br /> ------ <br /> ---- ------ ---- <br /> Disposal tftl5pq if Requirements)------ <br /> ------------------�2----------- - - -- -- -------------------------------------------------------------------I- <br /> -------- <br /> -------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby codify that I have prepared this application and that the work will be done in accordance with Son Joaquin County <br /> Ordinances, State Laws, and Rules-and -Rogutations of the Sm Joaquin tocal-Health District. Home.owner or licensed agents <br /> signature certifies the following: <br /> "I codify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed------------------------------------- <br /> --- -- ------ ------- ---- Owner <br /> By---------------- ------ - _ZA <br /> -----Title---0 �_ _ ------------- -------------------------- <br /> (if other than owner) <br /> FOR EPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------- ---- --- ------ -- ------------------------- -----------------------------------------------DATE.-------7`. ------------ <br /> DIVISIONOF LAND NUMBER------------------------------------------------------------------------------------------------------ ---.DATE----------------- ----------- ---------------- <br /> ADDITIONALCOMMENTS----------------------------------------------- ------ --------------------------------------------- -----------------------------------------------------I------------- <br /> ----------- --------------------------------------------------------------------------------------- --------------------------------------------------------I----------------------------------------------------- <br /> -------------------------------- -------------------------- ------------------------------------------- -----------------_----------------------------------------------- ----- -------------------------------------------------------------- ------- -------- <br /> ----------- - ------------- <br /> Final Inspection by: -- ------ -----------------------------------------------------------Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />