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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION.FOR SANITATION PERMIT <br /> -------------I..'_............­.... .. ............. <br /> Permit No.7!9-2/__ <br /> (Complete in Triplicate) <br /> .......... ................ ............ <br /> Date lssuedl/.7�3-7,9' <br /> ................ ------ ............. this Permit Ex I pires 1 Year From Date Issued <br /> Application is hereby made to.the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with Count OrclinaVe No. 549 and existing Rules and Regulations: <br /> ...:W <br /> 4:9,� d <br /> JOB ADDRESS/LOCATION 2. 22- -------------------------CENSUS TRACT...'............................................. ........ ........... <br /> Owner's Name ........ ............... ---- - ----- ...... Phone.................... <br /> Address .. <br /> ----------(_ ....... Zip--------- _--_ <br /> . ........ ... -------------- --------- ....... City. ----------- --- - -- <br /> Contractor's Name......................... ....-.--.-----...License #34-�_-._�_3_Ykl <br /> Installation will serve: Residence Apartment House F] Commercial [3 Trailer Court ❑ <br /> XMotel F-1 Other.............................................. . /I <br /> Number of living units:-----/_--Number of bedrooms...c;2-.Garbage Grinder-_--- ......Lot Size.... ..... <br /> Water Supply. Public System and no-me.......7..................... -- ---- ---- .........1­-------------------­1-------------------------------------PrivateX <br /> Character of soil to a depth of 3 feet: Sand 0 Silt E] Clay <br /> Peat ESandy Loam [] Clay Loam E <br /> Hardpan FAdobe ❑ Fill M teri I.- .... ....If <br /> 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-.tonk or seepage pit permitted if'p' ublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK' Size........... --------------------------- ---------- ......Liquid Depth--- --....----- <br /> Capacity-------------- _ •.Type <br /> -------- <br /> Capacity...... .....___Type----------------- ... Material ---------------- --------No. Compartments------- .......... ...... <br /> Distance to nearest; Well.:..-------"---.. Foundation------ - ------.......Prop. Line...... --------- -- <br /> LEACHING LINE f I No. of Lines ...........................Length of each line.------.--.--_---..------_ Total Length .. ..........__-------------- -------- <br /> 'D' Box............Type Filter Material........ .......--..Depth Filter Material.- .--------- --------- --------_------ ------- <br /> -_Distance to nearest..Well---------...................Foundation-------------------.--------Property Line----------------------------------- <br /> SEEPAGE PIT Depth................Diameter............___ ____Number...-------..__.._._.--..------ Rock Filled Yes El No <br /> Water Table Depth------------••-•-----------------------------------------Rock Size... ....... -----­--------------- -- <br /> . <br /> Distance to nearest: Well------------------------------------- -----Foundation.............. Line='----......----.--Prop. ....... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------- ------I--- --- ----- -- - -------------Date----. ------------- <br /> Septic Tank (Specify Requirements)---------------' ----------------------- - .............. ......It--------------- <br /> --f-------- -----------I------ - ----- --- <br /> Disposal Field (Specify Requirements)....-d-104d......../40Z)_. .... . ....... <br /> -------------------- --- --- -------------------- .............. ---------------------- - - ---------- ---­­­--------------------­ ------------- -------------- ------- ......... <br /> --------------------------------- ...............­- -----------------------------------------------------------------*----------------------- ­1­1----------- ................_----------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 /> "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 <br /> __- subject/ � <br /> k <br /> an sAo _nVsarion Pawsws of California." <br /> Signed ... 7 <br /> ------ ----/--------- --Owner <br /> By------------------------------- ...... <br /> .. 6y ­ Title. <br /> (Ifother than owner] ------ ----- -- <br /> ------ <br /> - ........... ............. <br /> FOR DEPARTMENT USE ONLY <br /> L _Z7 <br /> APPLICATION ACCEPTED BY.................. --------------- .......... ....... .................... DATE':-��. <br /> --- --------------- <br /> DIVISION OF LAND NUMBP . ...... ............ ......... .. .... <br /> ,7 DATE ---- ... ....... ................ <br /> ADDITIONAL COMMENTS,.� .......... . ..................... . <br /> -- -------------- --- ---- ..... - ----------- --- <br /> ............... -------------A�r -- - ------ -------------- -- ----------------------------------- --- ----------------- ------------ <br /> ------------ ....... ....... <br /> ----------- ------- -------- <br /> ------------------------ <br /> -----­---­----------- ............ .................................. --------------- ------------- <br /> ---------------------------------------- <br /> Final-Inspecfion by:............ -------- ------------ ---------------------------------------- ------------------------------- ......... ---Date.---- ------------------- --------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />