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_ FOR OFFICE USE: <br /> FOR OFFICE USE:- APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> ---•-•-•-••----- ----------- _- .......... (Complete in Triplicate) <br /> Date Issued..):, ;� 7-7P <br /> „ -- --------- ----- <br /> al Me-alth bistr:ct fta permit to construct and-install the work herein described. <br /> Application is hereby made to the,Scin J•oaq <br /> with County Ordindnce No.A9 and existing Rules and Regulations <br /> This application is made in compliance <br /> _ <br /> ---ter <br /> :_ _ - ........... <br /> ° .�.• .. <br /> JOB ADDRESS/to ! N.; <br /> .... ph <br /> ---------SUS TRACT......;-TRACT .�... <br /> _ !.. one- ..... <br /> J <br /> Owner's Name.,....- --- <br /> r• . . <br /> - <br /> // � 1 <br /> •s �r rr ,�.�� t�.�. tf :.:'o----. ----.......... .-�.•'..... <br /> � zip <br /> Zip..- <br /> '-- <br /> -- <br /> . ( <br /> cit _ ........... <br /> j <br /> ❑ ! r Phone:- 9 �License --- --Address. urt ❑Contractors Nao Trailer o{ ! t, C a8enCe mmercApartment House <br /> Installation will, serve Resii <br /> \ <br /> 1 ! ..:.._�.......; .. <br /> Motel,E]­ ! er-_ .............�;�-:•,:.', <br /> r <br /> t ; <br /> th .- <br /> Number of living vpits::,�.:�--}-----Number of bedrooms_...Garbage Grindex ;.Lo�.Size__•.. , Private <br /> r r A t riv <br /> Water Su I Public S stem and'name--: ----•=..._.. . ..,•`-...-:--••------•--- =...... 2 . :... .. <br /> -- - :.,:.., .. <br /> to <br /> Peat❑ Sandy;Lo ❑ Clay Loam f <br /> Character of soil.to a depth of 3 feet: I Sand ❑ Silt❑ Clay ❑ s _.,.. . <br /> ... . " '.Hardpan Aao e❑ Fil, Material-.-.. . ..-.lf yes,type....-..... ...-._.. <br /> t !: . t f <br /> (Plot plan, showing size of lot, location of.system.in relation to wells, buildingsL etc-mvst-be-placed on reverse side.} <br /> NEW INSTALLATION:'"--';(No`•septic tank;.oroseepage•pit permitteQd°if /public ewer is available within 200 feet,) s �� <br /> „ Size fJ -' '' ....................! .Liquid Depth.�'� <br /> PACKAGE TREATMENT 'j `J SEPTIC TANK ' <br /> t ,�y ..t!,N mpaltments-'._ ------------- <br /> ah. <br /> i <br /> i <br /> 'Capacity' �. Pte.1 bc- a x <br /> o;�Co <br /> } <br /> Distance.tonearest:.Weli__l.Q �•= - <br /> Prop, Line.-_.._.-;•__-_.-...-- <br /> ! _ .._/Leng o ea h line..-::.' Q.f -•- Length........... <br /> ;- Total <br /> LEACHING LINE _No. of,tines.:,�.,•--.---•• p�1 <br /> • ' <br /> -' De th Filter Material...�Gl- --- <br /> -^��Type_F.ilter atenal_ <br /> • --------- <br /> 'D' Box.. -. P <br /> ' .t F undation-.--�- - ---� ...... <br /> rest- <br /> Li <br /> :Distance:to nearest:Well..-._f.. . ,--...__.-.. <br /> 4Y OF .. . N <br /> SEEPAGE PIT Number-. -•---------- . - <br /> De th Diameter. <br /> Rock Filled Yes o' <br /> • i. <br /> ---- -- Si �r� <br /> J. <br /> ` <br /> :.Foundation._:....... ..............Prop: Line-:._.. ..� ' <br /> ( f Distanceao nleorest:Well..'-:�. B # <br /> S e ......•---------------•-. . --- } <br /> .Dat . <br /> ! 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_ , <br /> �. ....._---• --------•----- --- <br /> Septic Tanki(Specify Requirements)------------------- - ••-•••---- . € <br /> --........ <br /> Disposal Field.(Specify Requirements}_......:., ••.:_. <br /> ........ .......... <br /> . <br /> i'i,.---------------------------------- <br /> r <br /> ....................... .•rte..�. _ ___ <br /> ........ _ ------------- ! <br /> -..- ..- -'---=•.........:.:.......................:......`--------------....•.........-•--'--',-•--••-'-.------ .--...�. ._____._._...-..._ • .....-._- -' . <br /> I <br /> l , ” ' (Draw existing-and required addition on�rwverse side) ' <br /> and that.the :work will �s�done in accordance with-San-Joaquin County <br /> 1 hereby terrify that I have prepared,this application , <br /> Ordinances,` State Laws; and Rules>and Regulations of the San Joaquin Loc l Health District, Home owner or licensed agents <br /> �._ <br /> signature certifies the following: ; e arson in s'ucFi-manner as <br /> "I certify that in the performance ofithe work'for which this permit is issued,.l slhall not employ any p t <br /> to become subject t rkman's ,Com sation la of California." � <br /> -. . <br /> Signed-, A � <br /> ---------- --- ........... <br /> xsJ le <br /> BY' Tit ,. '�- <br /> ! (If other than ow+rier <br /> •FOR'DEPARTINIfNT'USE ONLY ' <br /> _- ... <br /> �DA <br /> E. . -- ------=-----•-APPt1CATiON ACCEPTED BY:_-•_ •---- --- <br /> E. : :. <br /> lDIVISION OF LAND NUMBER........................ . ••-••--...-:...- <br /> ADDITIONAL COMMENTS---- ..:_ ;_ .. -..-.... -- ---------------`..---.... .....---•------ <br /> --- <br /> ---------------•------••- --- ---•- <br /> ------------------•-•-......---- -•----....... .- ---- -- . --- <br /> • •___•_-ry........ ............ ..... ------------- <br /> ---------- <br /> _ -.._...._.-•__--_•- _-•------- _._.-.._-••____. .- -.-. <br /> .._.. ...._- <br /> •-------..-•----. Date J '-. <br /> Final Inspection b — <br /> Pal 21E77 REv,7/76 3M <br /> EH 13 14 SAN JOAQU LOCAL HEALTH DISTRICT <br />