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FOR OFFICE USE; FOR OFFICE USE; <br /> APPLICATION FOR SANITATION PERMIT' <br /> --------------------------- ----------------- <br /> (Complete in Triplicate) Permit No...7T- <br /> ............ <br /> -------------------------------- ....... ....... <br /> Date Issued-YI./ ----- <br /> ..............................�­­.................... This Permit Expires I Year From Date Issued <br /> Application is he'reby made totheSon 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 /> JOB ADDRESS/LOCATION.JY,..I!?.D...-,L�4KRFORD..CENSUS TRACT........... ----------_........ <br /> Owner's Nome... ....................... ----------:--••---•...............:......Phone. 7 C... <br /> Address_�4.A?. E.... .......................... -------_------- ------------------------- ---- -- -----City............�­.­......... ...........­---Zip..... ------ ---------- -- <br /> Contractor's Name..---_0.1�,N#?57R. ........._ ...... ------------------ - ---­­.,......License #.................._.......Phone..... =•----------------- ------ <br /> Installation will serve; Residence;K Apartment House ❑ Commercial ❑ Trailer Court E] <br /> Motel E] Other <br /> Number of living units:--- ---------Number of bedroom s_ 3_ Gar b, age Grinder. ---- ---Lot Size.. ............. ----- - <br /> Water Supply. Public System and name -------------------------- ......................... ...................... ...­­---------------------- -----Private <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand [D Silt[] Clay El Peat El Sandy Loam Clay Loom E] <br /> - Hard pan-EAdobe Fill-Material:..... Ifyes, tyt E <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NJ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted i�, public sewer i <br /> P y pvoilable within 200 feet,) <br /> Size <br /> _,X ----------- --------------Liquid Depth------- ... <br /> PACKAGE TREATMENT SEPTIC TANK D�) . .7 0. Compartments.-.....:7:......................• <br /> • Capacity).2_0.6 Type-rr��-.. �Mate-rial-c'et7�-�__ _ "I <br /> Distance to nearest: ......... -----Foundation 6)........ Prop. Line----------- --------- <br /> LEACHING LINE No. of Lines _011--e................Len Lenh offe h ........... Total Length ......... ................. <br /> LF <br /> 'D' Box-- ... ... ------------------ <br /> 1 '0 Material-------- --------- <br /> ...Type Filter Materia Depth Filter Mat <br /> Distance to nearest: WelL__._5_ - .......Foundation----1--d---------------Property Line-_.-- ­------- .......... <br /> / jameter----3-3.?_/Number--....0 Rock Filled 'Yes)e No <br /> SEEPAGE PIT Depth...9._� .. D ------------­ :1 <br /> WaterTable Depth-------------------------------------------------------- Rock Size_...---- ---------- --------------_------_-- <br /> Distance to nearest: Well_... ----------- ........ -------------Foundation..... . ..................Prop, Line_-.....-.-...---......... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------- - ---------Date-------.:-----------....----------------------} <br /> Septic <br /> --Date------- ......... ---------- <br /> Septic Tank (Specify. Requirements)-------- ..I................ .................. ............ ...................... ----------­- --------- -------­ ............ <br /> Disposal Field (Specify Requirements)..........--- - ------ ----- ................... --------------------------- -------- ------------------ ..........­--------- <br /> --------------I.............._­-----------------------------------------------­ ..........................­_._ ............... <br /> .................I-------------------------------------------- _­ ......... <br /> ---------------------------__11-----------------------------------------------­­----------------------- -- ------------ -------------------------------- ------------------ <br /> {Draw existing and required addition on reverse side) <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 Son 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 subject to--%V man's Compensation laws of California." <br /> Signed :Z Own&r <br /> By--------------------- <br /> --------------- ------------------------- ­------- <br /> . . ... ............ .............. ......Title------------------------------------ ....... .................. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 4 <br /> 3E <br /> APPLICATION ACCEPTED BY------, <br /> Y------* -----------/--/- <br /> CS <br /> ------- DATE------ ------------------------ . .. . ......... <br /> DIVISION OF LAND NUMBER ............ .. ............. ....... . ... ....... --------------- <br /> ADDITIONAL COMMENTS._..... -------_----------- _--------- — - - -- -------------------------------------- -------- ---- ----- <br /> _ -------------­ ------ - ---- ---- <br /> ---------- ------------------ --- v ----------------------------- <br /> --------------- --­---------- ...... ------------ ----------------------------------------------------- <br /> . ............. --------------------- <br /> . <br /> .......Date. <br /> Final-Inspdcfion by:.. ----------------- -- -------- - F&S 21677 REV. 717 <br /> EH 13 24 e. LO9-4L HEALTH DISTRICT <br /> SAN JOAQUIN <br />