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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------- ----------- -- . .. -ZO <br /> (Complete in Triplicate) Permit No..-� ""- <br /> i �) <br /> Date issued.- .._ ------------ <br /> ------------------­-- This permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> This application is made in c mplian e ith County Ordinance N 4 lsting Rules and Regulations: <br /> t110�] S, .�r�G '7v �Caj., �s � <br /> JOB AD R SS/LOCATION •�.... . .. /5,__ -Q�I4�C.... CENSUS TRACT <br /> Owner's Name:.". �1 1 ._. �. � .: ... ^.7 -_.._ -- .. . . .Phoner46�t--3.-.0eq.3�..- <br /> Address - ........... �,j.,. .-5 -.0"""....." i.:......-- .... Cit Zi <br /> V-5155-57.0 <br /> Contractor's Name-Par ki5 �40--. .............. ---License #-.--•.......................Phone------------------------ <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court,❑, <br /> Motel ❑ Other-­'.. ............... <br /> Number of living units;......[--------Number of bedrooms----2--.Garbage Grindar............Lot Size........... ... ....................... -.. _ .. <br /> Water Supply: Public System and name..............................".- --#'rivate ❑ <br /> - -�-- '-•-:-•-- <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdolA- ❑ Fill Material.. .... ....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 sewq is available within 200 feet,) <br /> � rl• <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [�j Size.. jr <br /> °\ 4a... Liquid Depth.-.. Q a <br /> [ Capaciry..V7110.0._....Type---12-4-4ti` '-- .. Material-- --.:No. Compartments-----. <br /> - ...... ...- t <br /> ' <br /> Distance to nearest: Well------ Q-- -- Foundation-.-1_0_-+7 ral Lengthroe <br /> LEACHING LINE [ ] No. of Lines ..-..' �:.- ----- Length of each line.....- <br /> 'D, Box-_A—.-Type Filter.Mater-ial.- _..._ •. ..Depth Filter Material...................-------------------- ..---...- ........ <br /> Distance•to nearest: Well_...�7 -_ .........Foundation. C)7t'--""-.__------Property Line------------------------- <br /> SEEPAGE PIT --- Rock Filled Yes <br /> ��[ 1 Depth.... ----.."..._Diameter---- - --• ..-�-...Number,,--- --------------------•- Na❑ E]T <br /> Water Table Depth.-_-. ..--------- ------- ..- -----•-=-----Rock Size-- -- <br /> - -------------------- ----------•---------7. <br /> l <br /> .:: = <br /> f, <br /> Distance to,nearest.",Well.-"..--: <br /> ---- --------Foundation.----- _.. ............Prop. Line...................... - <br /> REPAIR/ADDITION {Prev. Sanitation Permit#-------------- <br /> ------ --- ----- - .............Date..---------•..... ---------- -------------- <br /> Septic <br /> - -----Septic Tank (Specify Requirements)-�' ----------•-------------- .. -- -----= ------------ <br /> Disposal Field.(Specify Requirements)...:._"---------•"-•-• -------------•-------=--------------------------------------- - ----------------------------- - <br /> ------- --------------• <br /> ---------------"----------- ---- .---------.. . .-- ----- --- ------ --- --------- <br /> ,R <br /> (Draw existing and required addition on reverse side) I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin '.County E <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed'agents <br /> signature certifies the following: +A <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.,Workman's Compensfition laws of California." <br /> Signed - --------------------------- ---------------- ---- --- -Owner <br /> Titl -------------- --- - ------------------ <br /> BY ---V -- A- -----------_--- -- ; <br /> If other than owner) _ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY... -----------------DAT! _.". .. ...fir" ...') ... i ...." <br /> DIVISION OF LAND NUMBER. - '----- DATE... !. <br /> ADDITIONAL COMMENTS.- ------ - - --. - ` " ----... - - -- - --------- <br /> -- <br /> /� --- <br /> r ............ . _ <br /> .. <br /> -----------------------�------ .... ------------- •----- - --- --•--....---- <br /> ­­----­--------­--­---- <br /> ...... .................. <br /> ---------------------------- ----------------------- <br /> ...... <br /> -Inspeciion by: !N . --------• :............. ..Date .,� -0. --...---- ------- <br /> Final 1 <br /> - . .. <br /> EH 13 24 �SANJIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M <br /> i <br />