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FOR OFFICE USE: I <br /> ! <br /> FOR OFFICE-USE: " <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ---- (Complete in Triplicate) <br /> Date Issued6_"�"S` <br /> ___ <br /> is <br /> _' This Permit Expires 1 Year From Date Issued C <br /> - -------------rI <br /> work herein described. <br /> Application° s b mode to the San Joaquin Local Health DisNat ftrict for <br /> a d exist ng Rulconstruct <br /> and Regulations: <br /> This application is made in compliance with <br /> ,.._.. Y � <br /> ---.CENSUS TRACT------ ----- - --------- -=---s <br /> JOB ADDRESS/LOCATION_-_-, <br /> - --- -- :- <br /> ` r _ -----Phone._.------------ <br /> Owner's Name_------ <br /> . <br /> Zip <br /> l Address--- --- 1 . - - <br /> �- *J <br /> .• - ��•�.�.� �� -- -------License #- ---'��----�• --Phone ------- --- ---- <br /> Contractor's Name------- - . „. .h _ ..... . .. <br /> Installation will, serve: <br /> Residence �Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> Othe`k == =Motel <br /> �!.Garba <br /> _Lot Size __- $ <br /> Number of living units: --_ . Number"of,bedrooms___.-_ g Grinder...___ pnvat <br /> r , . <br /> Water Supply: Public System-and name--_- ------ ---.._---------j <br /> r Sand Loam [�Clay Loam ❑ <br /> . R- <br /> Character of soil-to a depth of 3 feet: Sand ❑ =Silt❑ Clay ❑ Peat ❑ Y _ <br /> �..,. -- --- <br /> Hardpan ❑ ` Adobe ❑,# Fill Material_....,_-.-_If yes,type----- - d reverse side.) <br /> Plot Ian, showing size .of lot, location of system in relation to'.wells, buildings, etc, must be place on r e• <br /> P N <br /> NEW INSTALLATION: (No septic tank�or seepage pit permitted if public sewer is available within 200 feet,) # <br /> ' SEPTIC TANK' [;� Size'--v- --------------'--------------------_ : Liquid Depth._ { <br /> r PACKAGE TREATMENT _ <br /> R. <br /> ' `. . , n <br /> s. <br /> Type---------- --------'---Moteria[--= `----=-No-Compartme <br /> 7TCapacity: r ----------- <br /> - <br /> = _ - Prop. Line_------ <br /> nearest: Well-=-------------- ------------ ------=Founda ion - - <br /> ..Distdnceto <br /> - ---------------- <br /> -------No of Lines. Length.of each {ins::'.: ,:-------.. Total .Length <br /> LEACHING_ LINE, L :] -----_-' <br /> YP , Depth Filter Material--- <br /> 'D' Box._-------:--T a Filter Material _ - = <br /> Distance*to nearest: Well______ F __ _.-- Property Line <br /> - <br /> ---------------------- <br /> . <br /> # _ ,i;" nd�tio Rock Filled Yes ❑ No�❑ <br /> t` <br /> .. K <br /> De th---- ''------ Diameter~- Number <br /> SEEPAGE PIT �[ l P. ' � � ---- - <br /> r . .... . . <br /> E <. Water Table Depth.--=------i ize-.._ <br /> = oc <br /> ire <br /> Disti9nce`to nearest':Well_._--- ---------------------%-_-_Foundation----------=------------ -Prop. Line._.------------------ !NI <br /> : . ------------- <br /> REPAIR/ADDITION ----Date'-.---------------------- <br /> Sanitation " <br /> Permit#__ _ _(Prey <br /> -- ------ --- <br /> Septic Tank {Specify-Requirements] ..- - <br /> e Y - -- --��-----� ---1 - _ r-------------------------- "",4 <br /> Disp I Field (Specify Requirements)- -�����x - <br /> i( <br /> 1 <br /> -------------- <br /> -- <br /> 1 --Y------ ------- ---- - !i <br /> (Draw existing and required addition on reverse side) a `� <br /> ! 1 hereby certify that'I have prepared this application and that-the .work-will be done in accordance with San Joaquin County <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: <br /> t <br /> "I cerci that in the performance of the work"#or which�ttiis.permifis issued, I shall not employ any person in such mann-. gas <br /> to became subject to Workman's Compensation laws, of Calrfornla. <br /> t Owner , <br /> Signed_;_._ = -_----- ---- -- ,:� .1 <br /> itle_ - ------------------ ----- <br /> EY-------------------------------- i! <br /> (If other than owner) b <br /> FOR DEPARTMENT USE ONLY <br /> ----------------- --- <br /> DATE --- ---------7------------ ------=- -- ----- <br /> 05� <br /> APPLICATION ACCEPTED BY------- �- -- --- __ _ _-_- <br /> I DIVISION OF LAND NUMBER--------4-__.-------, - <br /> ' - ----- - ------- -- ---- --------DATE------- ------- - .-- ------------II,. <br /> ----------------------- <br /> - <br /> ---- - <br /> ADDITIONAL COMMENTS--------------------- -----:-- ---------- --------- <br /> i - _ ------------------------------------------------------------ _ _ <br /> ----------- --- ------ - ----------- - ---- ------ ------- -------- --- _-------- - - - ------------ <br /> ----------- <br /> 1� <br /> -- <br /> ----------------------- <br /> - - ------------- --- --------------------------- -- <br /> -------- <br /> ------- <br /> ---- <br /> -/ -J-- n-. -------------------------_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_- --------------------- <br /> ------------- - <br /> jj <br /> J - <br /> _--------- <br /> ---- <br /> ---------- <br /> F :1 Insecion b - -------------------------- <br /> incl <br /> --- _______ <br /> a <br /> F&S 21677 REV.7/76 3h <br /> EH 13 24 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> r <br />