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---� FOR OFFICE USE: <br /> FOR OFFICE USE: ;� APPLICATION FOR SANITATION PERMIT —S <br /> Permit No............. <br /> (Complete in Triplicate) <br /> ---••--•-----•- q <br /> :- - <br /> Date Issued(ar f f- <br /> II This Permit Expires l Year From Date Issued <br /> .._......•---------•--•-•-•...... --- 1 <br /> Joaquin Local Health District for a permit to construct and install the work herein described, <br /> Application is hereby made to.the San u g Regulations: <br /> This application is made in compliance with County Ordinance No. 549 and ex <br /> istin Rules and <br /> .....-- <br /> ---- .CENSUS TRACT..........- ..... <br /> JOB ADDRESS/LOCATI N..-..0 ,--Phone-. -- i <br /> Owner's Nam ...................... <br /> . City-- -------- ----- ----- -- ...... <br />� zi <br /> v.... <br /> Address.... -- .License #- ----- ------ -- - -- -- Phone..-----�,---• •----•--- --------- <br /> i Contractor's Name-------- -------- i- - -.--. ' <br /> artment House El <br /> Trailer Court <br /> I Installation will serve: Residence ❑ Ap <br /> ` --------•....--- <br /> ! Motel ❑ Other..... �----�--:--€ - - • <br /> I . <br /> Number of living units:......__ .'.---Number of bedrooms----------..Garbage Grinder.------- ---Lot Size. private <br /> f <br /> Water Supply: Public System and name.------ ----- ----------- Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> t Character of soil to a depth of.3 feet: Sand Silt E] Clay ❑, <br /> i Hardpan ❑ Addbe ❑ Fill Material—...-"- "-".If yes, type----------------- - <br /> Plot len, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) CP <br /> ( P <br /> - it ermined if public sewer is available within 200 feet,) C <br /> NEW INSTALLATION: .(No 'Septic tank or seepage p P Liquid Depth..------------ -� <br /> TREATMENT E ] i�SEPTIC TANK ( ] <br /> k� Size----- -- --- --•--•-------....,---•--•---------- � <br /> Type ..----Material ---- No. Compartments.. <br /> PACKAGE Capacity-..._...__ YP -- <br /> i; _ .....Foundation..---- ... ...... ..... Prop. Line..- ---- ----- ------- <br /> Distance to nearest: Well- ------------- <br /> 1 . Length of each line.------ ------------------ Total Length ... F <br /> LEACHING LINE { ] No. of Lines..--"------- ------ <br /> 1i <br /> 'D' Box......... --TYPe Filter Material.-. ..... .....Depth Filter Material..............--------- <br /> -+-.- <br /> I ___ ....Property Line---------- --- ------ ---- ---- `- <br /> Distant&to nearest: Well------------- " .._..-----.Foundation.....-•----------- Rock Filled Yes ❑ . No❑ <br /> I' <br /> kSEEPAGE PIT E ] Depth................Diameter--•-----......----- Number..-------- -----------••------ <br /> Water Table Depth......... -Rock Size. <br /> Distance to nearest: Well........:...... <br /> ------ -------- <br /> Foundation--- Prop. Line. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_-. ----• <br /> --------..Date-------.-. --- ------------------ <br /> REPAIR/ADDITION <br /> ------ ---- ] <br /> Septic Tank (SpecRe uire ..-....:... . <br /> I (Specify q mems)---- -....--•--...--- •--- ........... .. ......... ............. <br /> if ..._......-....------ •�- --- �--- ------•------•---- ----- --------....... <br /> Disposal Field (Specify Requirements)------ - <br /> !/y s��-.. --•- <br /> ------------ <br /> ---- <br /> ----- -------- <br /> ------- ---------------------------------------------- <br /> (Draw <br /> ------ ---------- --=---------------- <br /> (Draw existing and required addition on reverse side) <br /> ance with <br /> I hereby certify that 1 have prepared this application and that <br /> the the work San Joaquinlbe tocaldone in Healquin COuntl <br /> th Distriictt.. Home owners or licensed agent <br /> Ordinances, State Laws, and Rules and Regulations of <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner a <br /> pkn's�Caensatt <br /> on laws of California." <br /> St ned.-. ----...._'.. .. .. : �► :Owner <br /> to become sut to org � <br /> e <br /> ..---------- ---- ---------- <br /> Title....... .......Title..- - ' <br /> (if other than owner) <br /> M FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY..------- <br /> • ---- DATE...... <br /> DIVISION OF�LAND NUMBR. ... - -- ------- <br /> ----- --.....DATE------------------ <br /> -.-.-.-.--.-.. <br /> -- ------------ - -- ------ <br /> ------ ---"--•---------------------------- ----- <br /> ADDITIONAL COMMENTS.----•------- .....1-... ..--- -- .. --....... <br /> ----- ---..-.. <br /> .. .......... ... ------------ -- - ------ --------- --- ............... --- --- --.--- <br /> .. ................•-------- --------------------- <br /> � ...... ... <br /> ion be0 � l '- <br /> ------------------------ Date- ------ ---�-- - <br /> E Final•Inspect y:--- ... 21677 REV. 7/76 <br /> l EH 13 24 I1 - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> � - P <br />