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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> .................................... .................. <br /> (Cotnplete in Triplicate) <br /> ...................•----...................... <br /> ..----..--- Date Issued-7.....131 :n? <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> L <br /> Application is herebym ode to-the Sbn Joaquin Local Health District for a permit to construct and install the work herein described <br /> RegulatiopW.. <br /> This application is made in compliance with County Ordinance N�0. 549,1;d existing Rules qnd <br /> existing <br /> ....................... <br /> JOB ADDRESS/LOCVTlr........0 4?1... C;:_-1P0......... ENSUS TRACT.....--- <br /> R01 41�;7....... <br /> �12 r .........Phone.................----------­­...... <br /> Owner's Name....... . ........... <br /> ... ........ <br /> .. ............Zip. .:..:..... . ................. <br /> Address. ------ -.02 <br /> .......... <br /> n <br /> of <br /> ............... ....Lice'se <br /> Ph on ..................... <br /> Contractor's Name........./� <br /> 2- ---------- <br /> Installation will serve; Residence. Apartment House ❑ Commercial E] Trailer Court <br /> ❑ <br /> Motel ❑ Other-..,........................:...........••-- . <br /> Number of living units:......../-Number of bedrooms... Grinder _e....Lot S.ize.... — - <br /> y =- <br /> r <br /> 11 / .....Private> <br /> Water Supply: Public System and name.-.-.......... ......... ........................... ........................................................................ <br /> Character of soil to a depth of 3 feet.. Sand 0 Si11J[;J__.Clay C] Peat [I Sandy Loom [3 Clay Loom <br /> ❑ <br /> Hardpan E] Adobe fD,,-rill MateriaL;;6.�...If yes, type................................ <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,) <br /> PACKAGE TREATMENT SEPTIC TANK Size.......................... ...........................Liquid Depth:-.,.,..:...... <br /> Capacity....... _..........Type....................+•Material.,.......................:No. Compartments................................ <br /> Distance to-nearest: Well............. .............Foundation.......... . .............Prop. Line......................... <br /> ---------- <br /> LEACHING LINE No. of Lines.............................Lengt, of each line._......... ............__....Total Length ...................................... <br /> 'D' Box............Type Filter Material_*..................Depth Filter Material............................................................. <br /> Distance to nearest: Well............................Foundation.... .................Property Line................_..._........... <br /> SEEPAGE PIT Depth................Diameter----------------- ...Number..................!---------- ... Rock Filled Yes E] No <br /> WaterTable Depth................................. .......................Rock Size.:---............ .............................. <br /> Distance to nearest: Well............................................Founclati on..........................Prop. Line......................... <br /> REPAIR/ADDIT16N (Prev. Sanitation Permit ------ ............ . .............Date._..._..:-....---.---....--.---.---.---._.._..) <br /> Septic Tank (Specify Requirements). <br /> --- - ------ ....0,Y- , .............. ...X. -------- <br /> Disposal Field (Specify Requirements). <br /> ..........................___.........................:------ <br /> ................... --- ....................... <br /> ............................. ...... ................................... ............................................... ...................................... <br /> ...............................I.,........................... <br /> ....................................................... .............. ...................................................................... <br /> (Draw existing and required addition on reverse side) <br /> appand that the work will be done in accordance with San Joaquin Cour <br /> I hereby certify that I have prepared this app <br /> Ordinances, State Laws, and Rules and Regulations of the-San Joaquin Local Health District. Home owner or Iiiensed ages <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 <br /> to become subject to Workman's Compensation laws 'of California.." <br /> Signed ...1---------- ..... ..........................Own" <br /> By.. Title----- .............. .................................... <br /> ....... ................. <br /> (If other than owner) <br /> PO IP DEPA!gMENT USE ONLY' <br /> ..........DATE�... -- ----- <br /> APPLICATION ACCEPTED BY....... T, <br /> A, . ..... --- ..........•.. <br /> DIVISIONOF LAND NUMBER. .........................4............ ....................... ------*­_q------ .............DATE........... .................. ............. <br /> ADDITIONALCOMMENTS............ ......................................... ................................................................ .................... <br /> ................................... <br /> ............................. ............. ................. <br /> ......................................................... ............................. <br /> ......................................... ............................. ........... <br /> ......................•••......_.......---•---•--•----.... ...••. ......-•••-•---•-- ........-•--• -••-•.......-- <br /> .. ..................:------------ );010&...........­.-A-->.....----------- .......ate Q.---------- ------ <br /> ....... ------ .. <br /> Final Inspe6ion by:....... .Ovr.� ... <br /> . .. ..... <br /> FLS 21677 REV. 7/7 <br />