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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------- � <br /> (Complete in Trip:icate) <br /> No <br /> Permit --- __--------------- <br /> r. " <br /> r This Permit Expires 1 Year,From Date Issued <br /> - Date Issued.............______ <br /> 6-1 <br /> ----------- ------ <br /> Application is hereby made to the San Joaquin Local Health District for a perm ti toconstruct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: s <br /> JOB ADDRESS/LOCATION.__�1 . <br /> �j <br /> f �---------- - ------------------------- i .`_._CENSUS TRACT. <br /> Owner's Name._.-----------,__- - Phone..-----.---------•-- ------------------ <br /> Address <br /> -- ------------ <br /> Address---- 7Z 4 1a <br /> :-sxi- CitY ._i._..-- - zip ` �'7.7"Q <br /> _.:. .r. <br /> Contractor's Name_. __ - --- -----------------------License #�3G .7 -1--- ---Phone_cc ------ <br /> Installation will serve: Residence Z. /Apartment House.E] Commercial ❑ Trailer Court ❑ <br /> r "~ „ :. <br /> Motel [] Other-----------------' <br /> ` Numbe4ro f living.units_______ _ Number of bedrooms_. _--._ ----------------------- <br /> Garbage Grinder....."",_____Lot,.Size__ --------------- -,_____, ' <br /> Water S`pply: Public System and name`._.__: <br /> �. P r' �----: ---I-- --- -- -------------- - ------------ --------------- ----------------Private <br /> Character of soil to a depth of 3 feet: _,Sand Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Ladm [Q-� <br /> I ' <br /> f <br /> �,. 'Hardpan ❑ Adobe ❑ Fill Material__ --------.!f yes, type___________________;_:_ <br /> (Plot fa'n, showin i-•y' ,----.._...... .f - _ <br /> 11v p g,,size of lot, location of system in relation to wells, buildings, etc. must be placed` -reverse side.) <br /> EW`INSTALLATION: (No septic tank or e�epage-pit permitted if public sewer is a'ifable withiW200 feet,) <br /> PACKAGE,TREATMENT [ ] SEPIC TANKti j Siie- --- -- - ---------------F--------------------Liqu <br /> id Depth <br /> _ <br /> Capacity` L s_Type :_ :Material` = `------- ' No. Compartments- ---- - -- -- ---- <br /> .*+ <br /> ._ Distance tolnearest:.Well.:_ __--- Foundation:._ = Prop, Line----------------------- <br /> 1 <br /> LEACHING LINE., [ l ---------------: - = <br /> _ _ e <br /> Box--=----•- ----_Length of line.--- --•--�`-�`��Totai; L ngtlti.- ----•- : ----- <br /> 1, <br /> --TYpe Filter Mater.ial`._ ~k"�Depth Filter Material-____:-.___"__-.-_-_'-------------------------------------- <br /> Distance to neare.st:-Well"~--~--__�_-- --------Foundation__._____.__ __.Property Line------------------------ <br /> SEEPAGE <br /> ___._._____ <br /> r <br /> SEEPAGE PITS "". :. ,cam. .. 1.,r: . . --- ----- -------------- <br /> [�1=--Depth------------I.-.Diameter ------- Numb'er <br /> i -------- Rock Filled Yes❑ No Ell <br /> • ...Wa -:Depth----'---'--.-'! ,. <br /> ter 7abJet '---- .� --- -Rack Size C <br /> Distanc7 n crest: Well-_'.- _ _'----.'------ f <br /> L -----------.Prop• Line-------------------- <br /> .- <br /> i REPAIR/ADDITION (Prev.'Sanitatiori'Perm'it#-_'_�__ ___________ i Date-_____.:___._ _..------------------------- <br /> Septic <br /> __ <br /> ----------------------- ---- <br /> oun anon---------_ ------------- <br />' Septic Tank (Specify Requirements)------------------- <br /> - _ a <br /> .. <br /> f Disposal Field (pecifRequire ennts) ,--- --��__�0.! -__-� } i <br /> ----- - <br /> ----- <br /> = = =t t . <br /> -------- ----- <br /> { ;.. - -- --A ... ----- ------- ----- <br /> rrrj, : (Draw existing and required add ition:on-reverse side) <br /> I hereby-ceetify that) have prepared this application and that the work wily 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: <br /> "i'certify that in the performariie -of'the'work for-which this permit'is issued, I shell not employ any person in such manner as <br /> to become subject to Wo roan's Compensation laws -of California." ; <br /> Signed------- -- - - ------- - i <br /> gY Owner <br /> J ---- . .. . _. -_ . <br /> .fesTile Com_- - `"` <br /> (If other"than ;owrier) (L ai Ci SEPTIC TANK SER. <br /> FOR DEPARTMENT USE ONLY P. <br /> a. Bax 94 <br /> APPLICATION ACCEPTED BY t "= - -------------- = -= - - - DAI� ;rf? i22 <br /> ----------------- <br /> DIVISION OF LAND NUMBER------------------------- - DATE-------- <br /> ------------------------------------------ - <br /> ADDITIONAL COMMENTS------------- ---- <br /> ------ ------- ---- --------------------- ------------------ ---------- <br /> ---------------------------------------- - . <br /> .. ; <br /> ----------------------------------------------------------- ------------------------•- -- ------------------------- --- -- - <br /> - r ----------------------------------------------------------------- J � -----------------'Final Inspection by:---�- --- _ = "_�. Date. - <br /> Fes 21677 REV, 7/76 <br /> ------ --- - ----- ----- <br /> EH 13 24 SAN JQAQLIIN LOCAL HEALTH DISTRICT ' son <br />