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�. <br /> FOR OFFICE USE: <br /> OR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ` � <br /> ------- (Complete in Triplicate) <br /> �-`-��o--- <br /> = <br /> Permit No.. <br /> z <br /> Date Issued__._..S- &_77 <br /> ----- ------------------- <br /> _--. <br /> This Permit Expires 1 Year From Date Issued <br /> ------------ --------- ------------------- _ _ . --- ____ <br /> Application is hereby made the San Joaquin Lncal-Health Distriat:for-a permit to construct and.install the work herein described. <br /> This application is made in compliance with County OrdinancFNo.549 and existing Rules and Regulations: <br /> �. <br /> ----- -----'- -----:-.CENSUS TRACT--------------------------- <br /> JOB <br /> -- -- ---- ------ -----JOB ADDRESS/LOCATION.- ----- <br /> i2_R- -{----- <br /> Owner's Name.. ' ------- -- <br /> City- <br /> Address <br /> it <br /> Zip <br /> Address------ ------- ----------- �_�� - .-..�---a�/�TtP. --- -- Y- - � -- -- <br /> - '` <br /> -- <br /> �ri` _T.-3-Phone-- <br /> Cr-:7 <br /> Contractor's Name---- --- --- License #-A; <br /> -- - -- <br /> Installation will serve: Residence (� Apartment House.❑ .„..Commercial 0 Trailer Court ❑ � <br /> I ------�_:-__ r7L <br /> Motel ❑ Other - ' <br /> ` ------------- ---- <br /> i Number of bedrooms_s ----Garbage Grin er'__ ------ Lot.Size--_. -,_____ _ <br /> Number of living units_____ __ c _ Private ❑ <br /> } <br /> �R_1_t- _ RTc-'z Yui- - <br /> Water Supply: Public System and name--- ------------ -- -- -- -� <br /> Character of soil to a depth of 3 feet: Sand Silt Clay ❑ 1 Peat [ISandy Loam E] Clay Loam,, <br /> Hardpan �. <br /> Adobe Fill Material._ _1------If yes, type-------------------------------- <br /> s ❑ i <br /> {Plofi 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 isilable within 200 <br /> ivfeet,) <br /> PACKAGE TREATMENT L ] <br /> 51 PTIC TANK [ l Sizer------- ----- <br /> --- ------ --Liquid Depth=--------- --- <br /> - <br /> Capacity =---- TYPe Materiol---------------------1`----No. Compartments_-------- -------------- ' <br /> --.Pro Line-------------------------- <br /> Distance to nearest: Well----------------•------ - -� _ : f Foundation----------------:--- p <br /> No. of Lines `- .Length of each line.__. -----;-.-'``--------Total Length'. <br /> LEACHING LINE [,] ------- ------------------- - <br /> tt <br /> :'D' Box__---_1-'__-Type Filter'Material-------------------Depth Filter Material-_---------------- <br /> .-. _. -------- -- ----- <br /> Distance <br /> -- -- <br /> - --. Foundation_ -- ------ -- Property Line __.__-- _ - - <br /> Distance to nearest: Well.........:. .. ... �. <br /> , .� Rack Filled Yes.❑ N <br /> SEEPAGE PIT L ] Depth--- = Diameter_:_ = Number ". _ <br /> .. _ . ., - ------ <br /> ` . . -. �. - .� � Size----------- ------------------------------------ <br /> Water <br /> ----- ------- ------- ----- • <br /> r i Water Table Depth--- ------------------------------------- <br /> LineRocF <br /> Distance to nearest: Well--------_------------------- ---------- <br /> Foundation: Prop. ------------------------- <br /> Date - - -- - } - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_F--------------------------------- y—` ' <br /> Septic Tank.(Specify Requirements)- <br /> Disposal Field (Speafy Re uirements}-_._ n , <br /> ------ ----------------- <br /> -- -- - <br /> -------=--- ---------------- -------------'-------------=-------------------- ------..----- <br /> ------------- <br /> (Draw existing and required addition on reverse side) <br /> once With one in accr <br /> I hereby certify that'l have prepared this application and it at ther <br /> the han Joaquinn Joaquin County <br /> work wllo aldHealth Distrctd Home wne6 or licensed agents <br /> Ordinances, State Laws, and Rules•and Regulations <br /> signature certifies the following: <br /> "I certify 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 becorpe sub'.ect�to rkman's C�nsation laws .of California." .- <br /> IKS - <br /> Signe + I <br /> d�� ------ ------- i <br /> Title---- <br /> ------------------- <br /> BY--------------- - -- <br /> - (if other than <br /> OR DEPARTMENT USE ONLY r� <br /> - ----- ------- ------- --- --- --- --- <br /> DATE. <br /> APPLICATION ACCEPTED BY.. _J--I�r - --- ------ ----�- <br /> __-. <br /> ----------- -------- <br /> . - � -------DATE.---- ------- °----•- ------ ------ ------- <br /> DIVISION OF LAND NUMBER---__ . = ----------- ----- <br /> ADDITIONAL COMMENTS____-- _-- ----------- <br /> --------------7----------------------------------------------------- ------------------------------- -- ------ ---------------------- <br /> -----------------------:-- ------ <br /> --------------------- -------------__---- <br /> -------------- -- <br /> ------------- --- <br /> ---- - ---- ----- <br /> -- <br /> - ----------- <br /> Final <br /> ------- <br /> ---- --- ---------------------- ---------------------------- <br /> ---. <br /> ---- --- - -= -- ----- <br /> Final inspection by:__ _-_-- - -� - -- _ - ---- - ---------------------------- - -- <br /> - F&5 25677 REV. 7/76 3M <br /> EH 13 24 N JOAQUIN LOCAL HEALTH DISTRICT <br />