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FOR OFFICE USE: FOR OFFICE USE: <br /> APP1 CAT ON FOR SANITATION PERMIT <br /> --------------------- �.�Sz <br /> ........... ................. {Complete in TriRlicate) Permit o... ........... ....... <br /> ........... <br /> Date Issued..�:l/ -7e <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 /> This application is made in compliance with Count Ordinance No, 549 a xistipg Ru s and R ulations; <br /> \-Jeol <br /> JOB ADDRESS/LOCA .9 .. ... --- .2.CYr...U'.� ------ - ------------- ------ --CENSUS TRACT.......---------- --------- - <br /> Owner's Name.... .. _ _. _- - ` �7 <br /> l } - .. ... Phone._... . .-' /��.--- --- . <br /> 6G �p / <br /> Address 1 - .. ------ - -------------- City d icy -�,c`,. ZiP = �` �?._.... <br /> Contractor's Name....... ----. .-___ ,- License #- ------. - Phone..- � --- <br /> Installation will serve: Residence partmenXouse ❑Commercial ❑ Trailer Court,.❑ <br /> Motel ❑ Other- - ---------_- --------------- -------- -t <br /> Number of living units:_-.-...�..-..--Number of bedroo - Garbage Grinder.__ Lot Size.-.:...2� ..K <br /> Water Supply: Public System and name .- T <br /> - <br /> •--------------- -­---------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam lay Loam, <br /> Hardpan2� <br /> Adobe ❑ Fill Material _.. ._..If yes, type...----.._-------------- f' <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,) r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Si e ....... ... . ..... .... Liquid Depth.... ...-. _.-......-� <br /> Capacity...L6.0 -Type _._.Material--------------- ---------No, Compartments.----.2-,.------ -------- --.-..H <br /> Distance to nearest: Well-_----/4Q ... .. ........ .........Fon ation.-.--SO.-.._.__... Prop. Line------..... ----.------Q <br /> LEACHING LINE No. of Lines 3--------------------Length of each line-. ------ --jp--.............. Total Length _. ..-,..�- ---------------- <br /> 'D' Box.. .. Type Filter Material..1_.y..........Depth Filter Material...-----..L�..............._.- --- ---------- <br /> � / <br /> Distance,to narest: Well------/--0.0_._.-----Foundation.-_-�.-�._.._.........Property Line....±��...I.................. <br /> SEEPAGE PIT 1-4� Depth Diameter... .._.....Number....:.3_................... Rock Filled Yes No ❑ <br /> Water Table Depth------------------------------- ------------------------.Rock Size. '. ... ----------------- <br /> ,e <br /> Distance to nearest: Well.----,<. .0-11------.._._I- --- -'-----Foundation...... _Q......_....Prop. Line..----- ---------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------- . ._..............Date-------.--...._-_----------_-- ---- ------) <br /> Septic Tank {Specify Requirements)...... .. ....... ----------------------------- ------------------------------ ------...----------- <br /> Disposal Field (Specify Requirements)........__ ............ ............. ............... ------- <br /> ..... --------- - ------------------------------- <br /> •(Draw existing and required addition on reverse side) <br /> I hereby certify that I have preZl-es <br /> e this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I cer ' a p rmance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to ome s to kn an aws of Califor <br /> Signed----.... ----- --------- -- ------ ..... ..........-------------­--------­­---- <br /> Title <br /> By..---------- - -------- -------------------------------- Title...... <br /> (If other ner) <br /> FOR DEPARTMENT USE NLYc, <br /> APPLICATION ACCEPTED BY. ---- •------- DATE .. ��'`... .... <br /> DIVISION OF LAND NUMBER--------------- -- ------------------ ----- ....---- -- ----------- --------- QATE.... <br /> ADDITIONAL COMMENTS-- --_................ -------------------------- -.- ------- <br /> ------------------------------------------------- ---- ..: -- �_.�----- ---- . ' �- ---- <br /> - ------- - - ........... <br /> I final lnspectlnn by 7 - � --- -------------- -------- Date. �' - ----- <br /> CH 13 24 a SAN AQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M <br />