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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT q <br /> Permit No.z!-.=. <br /> (Complete in Triplicate) <br /> q .. <br /> ----------------------------------------- ----------------- Date Issued .7.-/�`,7 <br /> -------------------------------- -- This Permit Expires 1 Year From Date Issued <br /> _ s <br /> Application is hereby made to the San Joaquin Locos Health District for a permit to construct and install the work herein described. t <br /> This application is made in compliance with ounty Ordinance No. 549 and existing Rules and Regulations: a <br /> 'l CENSUS <br /> TRACT---------------- ------ <br /> JOB ADDRESS/LOCATION--- a�_ -- - ---- <br /> + ------.Phone--- --------- ----------------- - ---- <br /> Owner's Name. <br /> - -"""� City - zip -------------- <br /> 's <br /> ------------ . ; <br /> a <br /> Contractor's Name -License #._3z ----Phone-------------------- <br /> Installation will.serve: Residence [J Apartment House:❑ Commercial ❑ Trailer Court ❑ <br /> y� "Motel r❑`� Other_:.�.v ----------- % ------ <br /> Number.of living units:-.-,--/--------- of bedrooms__.-__:,Garbage.Grinder____.__--.-Lot Size_________________________ _____________________________ <br /> w ? + <br /> Water Supply: Public System and name__ __.__ _-_____--- -----------------------------------Private <br /> ------------------ <br /> Character of soil to a depth of 3 feet: -Sand ❑ _Silt❑ Clay ❑'Peat❑ Sandy Loam ❑ Clay Loam ❑ , <br /> Hardpan Adobe ❑ Fill M r�idl­ -- ----If yes, type-------------- - --------------- <br /> - Hard 4 <br /> r kF. <br /> (Plot plan, showing size of lot,!location of system-in relation to wells, buildings, etc. must be placed on reverse side.) V <br /> NEW INSTALLATION: (No septic tank or,see age pit permitted if public sewer is available within 200 feef;J <br /> ��! <br /> PACKAGE TREATMENT [ 1 : SEPTIC`TANK [ . . Size-`T 21 r C� --------= ---------- -- Liquid Depth -----------------Q <br /> �.: Capacity-��� Type Material-=-- '�c.�-----No. CompartmentN=---- --------- <br /> � s 1 <br /> - � <br /> f Foundation._ -_l.<J---------- -.Pro Line-- ------ <br /> cDistance #o nearest: We11______________�O -_--_„_=-_.--` - PY � <br /> LEACHING LINE [41 No. of Lines----------13--------------Length of each line.------___._` __. _:______Total Length.__._;` ----------- ---------- <br /> i D' Box-.;__.t__;__Type Filter Material___._-/----Depth Filter Material-------- ___ ;__ ___. -- {-- <br /> Distance to nearest: Well_-.____--r�?----------Foundation---------- - ------- Property Line T.-- ----.-------- <br /> �� - - <br /> SEEPAGE PIT [ ] Depth---2�--__Diameter-----33 Number__________: _____________ f Roc01-i ed Yes No❑ <br /> % <br /> { Water Table Depth_ l �� =r- ---------- Rock Size,_._- - /r = <br /> 1 r <br /> Distance to nearest: Well-------�---�--I�_�-------- ----------Foundation--.-------�--`Q-----_..Prop Line----------------------- -- <br /> - <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------=-------------------------=----- -------Date- ----'---------------------------------- - <br /> AT <br /> � Te <br /> Septic Tank (Specify Requirements)-----.------------------------- ------------ ----------------------------------- --- <br />' Disposal Field (Specify Requirements)-------------- ----- ---------------------------------------1---------------- ---------------------- <br /> ---------------------------------- <br /> --------=------------ <br /> [ -------- -. ------------------- i <br /> ------- ---. --- ----------------- <br /> = ---------------------------------- <br /> ------------------------ -------- - ---------------- ----------- <br /> ----- <br /> --------------------- <br /> - <br /> F (Draw existing and required addition on reverse side) <br /> f <br /> I hereby certify that I have prepared this application-and that the work will 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 performance of the work for which-this permit is issued, I shall not employ any person in such manner as <br /> to become. sub;ect.to Workman's Compensation, laws o California.” <br /> CJ <br /> : Owner <br /> Signed ---- Tit <br /> � ---------------- <br /> ---- <br /> ------------- ---------------- <br /> t <br /> ---- - <br /> __By------- ---------------------- <br /> (if other than owner) k_ i <br /> �. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYT ----------:--- - ----------------------------- DATE-'.71/��-l— ----------- :--- <br /> � DIVISION OF LAND NUMBER -------_-- ---- ---------- ----- - ----------------- ---------------- ------------------ ------ ------ ------------------------ s--- <br /> ADDITIONAL COMMENTS------------- ----- ----------------------------I------------------------- <br /> ---------------------------- ---------------- <br /> ----------------------------------------- --------------------------°- ----------------------------------- ----- <br /> s, ------------------------ <br /> Final Ins ection b Y ---- ---- "=------------------ - ------------ -Date f ` <br /> y <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />