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C <br /> FOR OFFICE USE: FOI;_OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- L Permit No...7�J � <br /> '(Complete in Triplicate) <br /> --------------------------------------------------------- Date <br /> This Permit Expires 1 Year From Date Issued <br /> l <br /> Application is hereby made to the San Joaquin Local Health District,fora erTit to construct.and install the work herein described. i <br /> This application is made in compliance with County Ord inisnce'Na�549``ri`d`existing Rules and Regulations: y <br /> JOBADDRESS/LOCATION-. ------ --- ----------------------------------------------------------------.CENSUS TRACT---------r- -------------------- <br /> Owner's Name----- - ' -------------- --- -------------------------- ------ Phoneba� L."---�r <br /> Address - '; -------------------------------- ------ Ci - ne �_---------------------- <br /> .01 <br /> ' f - - <br /> �v P----------------- - <br /> Contractor's Name .. -----------License #. - Phone <br /> Instal lotion,will'serve: (Residence Y. Apartment House E-] Commercial ❑ Trailer Court ❑ <br /> Number of living units: Mone►�O— Other ---- / ] <br /> i - ' <br /> g Number of bedrooms."" ?/ ge Grinder_--_--.-----Lot;Size------�...> ,ra------------- ----- <br /> ______________Private <br /> Water Supply: Public System andname----- -i----�;� `��'ar--�------�--: -----",• -----�---�-- --------------- - - s --- ❑ <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ Peat❑ Sandy 1Loam ❑ I C1ZJY`b im <br /> Hardpan ❑ " Adobe K -Fill Material�j_..`;tf,`yes, type_.--.-3 -f-- -=------=--`.f <br /> k <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 epage pit permitted if public sewer is available within 200 feet,) , <br /> PACKAGE TREATMENT [i-]--SEPTIC T-ANK—[�] _ "�.. Site------------------- -------- --- ------------------Liquid Depth.------- -----=--------- <br /> CapacitY ,. TYPe -Material' No. Compartments = <br /> Distance,to nearest: We].1. -------=--- =------ --- -Foundation ----------------=,.._Prop. Line <br /> LEACHING LINE [A No. of Lines s---------------------------:Lenbth of each line :---" ._- _-___-_ Total Length.-­­!------------------ <br /> ! , <br /> # '-D' Box--.--.-- Type Filter Material:J------------------Depth Filter Matbrial---t'---------------- ---_ _ <br /> fF � � � Line I <br /> I ... .cE>to neap er °-.""""" - Number Foundation Property <br /> Rock Filled <br /> SEEPAGE PIT [a],� depth- --- r�r - ! � C� <br /> { Water Table!Depth__� �... `..- Rock Siie- --------�--- ----e5 <br /> Distance to nearest: Well_------ '------------- ------ ---- Foundation'.------- --------.Prop. Line------------- ------------- <br /> REPAIR/ADDITION (Prev. Sanitafiin Permit#-- ------------ ------€-------------------- ---_-.Date_- "— -) <br /> l <br /> Septic Tank (Specify Requirements) = =----- - ----------------------=-----------------------------------==----------------- "-------. -------------- ----- <br /> r r ,,�fJ <br /> Disposal Field (Specify,Regpirements)---- -Gu T` v"' ------------------------------------------------ <br /> ------ <br /> -------------------------------------- <br /> ------------=------------ ------ ----- t -- _ ;-- -- -- --- :. <br /> X ! <br /> r. <br /> -1 . . _. i <br /> ------------- <br /> i ( ' (brow existing and req iretl�addition,on�reverse.side) <br /> I hereby certify that'll have prepared this application and That�4l (work will be done�in ac cordance with San 'Joaquin County <br /> Ordinances, State Laws,! and Rules i and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that'in the performanie'of;the w�"rk for whic_4his permit is issued, 1 shall not employ any person in such manner as <br /> [ 1 i <br /> to become subject 4o Workman's Compepsgtian laws{,of. California." }, <br /> c� <br /> Signed --- <br /> ----------- ----- Owner <br /> a <br /> ' ---Title-----=------ - <br /> i <br /> - 'f other than owner-),,�, y <br /> OR 19PARTIASINIf-USE-ONL•Y- ``"""'"" <br /> APPLICATION ACCEPTED BY { --------------------- DATE ----------- - ----:----------- <br /> DIVISIONOF LAND NUMBER------=------------------------------ --- -- ----- --------------------------------- ---------------------DATE - --------------------------- <br /> ADDITIONAL <br /> -------;------------- ---ADDITIONAL COMMENTS------- ------------------------=-- ------------ ------ ----=------------------- ----I---------------------=-------- -------------------- - ----- <br /> - -------------------------------"- --------------------------- ---------------- <br /> ----------------------------------- <br /> Final <br /> ------------ ---- . ----- <br /> -------------------Final••Inspection by: ------ ------Date.--- �l <br /> EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677-REV. 7/76 3M <br />