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FOR 0FFICF .ISE- I OR C FFIfE IIV. <br /> APPLICATION FOR. SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.. - ___ <br /> -- - -- - -------- -. - .. This Permit Expires 1 Year From Date Issued Date Issued-?-1'4 <br /> A-pplication is hereby made to the Son Joaquin Lucal Health District for a permit to construct and in the work herein described. <br /> his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L CATI ---/rOPC _ ..�52?-(cr.._...__.CENSUS TRACT------------ <br /> ')wner's Nam �.e..-------- -------••--------- Phone <br /> -AddresslY,f _. JCityn7 - - <br /> - ZiP-Contractor's Nome_..- --.----- /-------------- --- - - ------ -- - -- ice - --- --.....-------- Phone.----- - - - .._._.-_..... <br /> -stallation will serve: Residence❑ Apartment [jause Commercial ❑ Trailer Court ❑ <br /> Motel -Onnthers. .SC -------- ---------------- <br /> Number of living units:.._-.l__-Number of bedrooms-.;;4.- .-Garbage Grinde�GC---Lot Size <br /> Vater Supply: Public System and name-- --------- --------- -•---------------- ••--------- - -- ----------------------------- - .--- --------_.Private <br /> Character of soil to a depth of 3 feet: Sand ❑ S' t Clay ❑ Peat Sandy Loam Clay Loam <br /> Hardpan E] Adobe�F.il❑ E] E] E]l Material-------- _If yes,type-.. .......................... <br /> (Plot <br /> 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,) <br /> ACKAGE TREATMENT [ j SEPTIC TANK [ ] Size--l-._loh. -.- �1.----:-_--__._.--__-_-Liquid Depth..... . ......... <br /> Capacity-� <br /> il:a - No. Compartments.-..-;L-.. <br /> ` <br /> Distance to nearest: Well....---_-L-e. ------------­-------- <br /> ngf Qf- ------ - --------Foundation------ ------..Prop. Line---------- -- - - .. <br /> BEACHING LINE No. of Lines _ ::,a,___-- .._.._p�. _______________Total Leneach [injth -___--_ _. . <br /> s <br /> . <br /> 'D' Box.../......Type Filter Mater- . <Depth Filter Material.. Z�--._-----------.---------- <br /> /---- <br /> -------- <br /> Distance to nearest: Well_. ,... -___-_._: Foundation-_ <br /> /()------------------Property Line__.d�............. ._.._,__.. <br /> SEEPAGE PITDepth-__.__._-. .- Diameter______._. mbf?r________---------- __-_ _ ___- Rock Filled Yes No <br /> [ ] . _... Nu ,- <br /> _ _ E]Water-Tab1e.'Depth:-•-':------------ -----------------------------------Rock Size---------- ------------------- --------- ---- <br /> Distance to nearest: Well. --..............._.. ._Foundation.--------•-----------_ Prop. Line.... .................. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----.___-_-- - - ._ .-_____-.Date---.--------- ----------- <br /> eptic Tank (Specify Requirementsl--- --------------- .......... -- --------------- -- - ------------- -- - - - <br /> Disposal Field (Specify Requirements)--- --------- ------- ............................. <br /> - -------- --------- ------­-------------- -------------- ••----•---••-- ----------• -------- ------------------------•---------- --------------- ............. . _. <br /> ------------ ------- ------ -------------• ............-• ----------•------ ------------ - -------------------••- ..------------- - _ --------- ------ <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this applicq#ion-.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 <br /> gentssignature 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 /> ecomett cman' Compensation, laws of California." <br /> Signe -- ----- - - -- -_._- ---- --._Owner <br /> ly----------------------- ----------------•-- Title_.... . _.. <br /> (If outer than owner) <br /> FOR DEPA )ENT USE ONLY <br /> APPLICATION ACCEPTED BY-_<2 j .... .................. -- <br /> DATE. -7— <br /> DIVISIONOF LAND NUMBER _- --------------_ _._-....---->-------------................ ------ ---•-•-------------------------- DATE............. - ---- •-- ----------- <br /> ADDITIONAL COMMENTS... <br /> ---- --- -•---------- -- - ------------------------------------ -----•-•---- ••••-- ------•-•••••----------------------------------------------••------------------_--...._.. ------------......--..... -- <br /> .----- ----•---------- -••--------- ------ ----• - - -------- ---------- ..-----•--._. ..----_......_-• ------•---- -------- --•-------•------------- _. -- ---------------------------------------- ------ <br /> --------- ---------------------•- ;= .......-----•----------------- --------------------•---__.-- <br /> - ----- ------- - <br /> inal Inspection by:. -- ------------------------------------------..Date-- �-�' "-�I <br /> .�+ 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> c <br />