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--- - I i -F - 'FV.,k-; k-, Wrn�-� AeACXAX-'51� <br /> 5Z1AA500A-Q- FOR OFFICE USE: <br /> OR OFFICE USE,, APPLICATION FOR SANITATION PERMIT <br /> • <br /> (Complete in Triplicate} . Permit No.17y:-�-/... <br /> ------ <br /> ­ <br /> ----------------- ..... ...................... Dote Issued <br /> --------------------------------- ---- -------------- <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made toLthe Son Joaquin Local Health District for a permit to I construct and install the work herein described. <br /> This'application.is mode.in complionce.with County Ordinance No. 549,and existing Rules and Regulations- <br /> ------------- .......... <br /> JOB ADDRESS/LOCATION ­--------------- .........CENSUS TRACT................... <br /> Name._:. : ..... . ....... ..........­­ ........ ........ ....Phon <br /> Owner's --------�-P­ <br /> City----a Its? <br /> .. ........ ... <br /> ............. <br /> .. ........ <br /> Address--,--- <br /> Contractor's Nome:-. ........­ ....License <br /> ................... ........... ------ ------- <br /> Motel M Other...... ­-- ------ ------ --------------- <br /> Installation will serveL,. Residence 0 Apartment House E] Commercial X Trailer Court M <br /> Number,of living'units:................Number of-bedrooms-....... Garbage Grinder---- -------Lot Size....-_...___.- - -- - ---- ---------- <br /> ---Private <br /> Water Supply: Public System and name.. ---.1........ ­------- --------­ �------------ --------------------- ------- ----------------------------,------ <br /> Sand ❑ <br /> ED SiltEl ClayEl Peat Sandy Loom'[:] Clay Loam <br /> Character of soil to a depth of 3 feef; <br /> %* be Fill Materi6l,c - -- ---- <br /> Hardpan E] �­ Adobe if yes, type................'--!..111�- <br /> 4J <br /> (Plot plan, showing size of lot, locbtian-of'System in relation'to wells, buildings, etc MUst be'-plUced on reverse side.) <br /> NEW INSTALLATION: (No 'septic;tank or seepage`pY,pe-ri-mitted.1tt-Oblic sewer is ,available within 200 feet,] *e <br /> -2- <br /> PACKAGE TREATMENT SEPTIC�TANK [ ] Sile< — .-- ......I .- <br /> .:!!-;--7------------- <br /> (A� <br /> Liquid Depth.- <br /> SE rt* Capacity:.5v ­---Type-- .... Mater a CJL e----No. Compartments----- - ----------------- <br /> Distance to nearest: Well-_.... .....-_..... . .........Founclation.----/0 ...... <br /> 10 ----------- <br /> LEACHING LINE rN No. of Lines .,...-..: ,:::..-:- .. Length..ofreach,line...---•--2�.- --•--- Total Length <br /> 'D' Box--. v-Type Filter Material /ZOV-49t,'�..Depth Filter Material—­/4------ ------------- ------­-- ----- <br /> p --—­-;' ' -11% <br /> .5 0'+7 .... --------- ......... ........I <br /> Distance,to necirest. Well------7 70---17 ---- -Property Line.... 5 . <br /> A F1 <br /> SEEPAGE PIT Depth ----Diameter-J-3 Number--- ------- -- ------------ Rock Filled <br /> YesNo <br /> Water Table.Depth--------- ----- ------------ ---- -- ------ A-oc� Size --------- <br /> r <br /> . Prop. <br /> Line.—S, ------ <br /> Ctistance to n P <br /> nearest: Well-------- ------Foundation----- <br /> Date--------:­- ---------- --------- ------ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#.... ........­­----- -- - ------- <br /> ----------------------------- ....... <br /> Sepfic Tank (Specify Requirements)--- ---- -- ------------------------------------i.......­................................... ......... <br /> .... ......... <br /> Disposal Field (Specify Requirements)-- ----------- I- -­ ---- ---------- ......... ----------------- ---------------------­............ <br /> II - .....I..... ........ .... ......... .......... <br /> -------------------------------- <br /> I ------------------ ........... . ....................I......... <br /> --- -------------- ------------------------------------ - --------------------------------- ----------- ---------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 'hire by certify thall have prepared 'thin application-and-that-the work-wili-be-done in-accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules <br /> les 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 subject to Workman's Compensation laws of California." <br /> Signed...... ........... . ... . .......... ------ ------------------ ....__Owner <br /> ----------- Title.......... ---- ---- --------- ---- ------- - <br /> By........... ............... ........ ------ -- ------- - ---------------- ....... <br /> (if er than owner) <br /> .FOlt DEPARTMENT USE ONLY <br /> APPLICATION "Poo -DATE .... ;;?. ..... .... ....... .. ...... <br /> ACCEPTED BY------ ......... ........... ................................. ...... <br /> ---------- .­....... --- -- ....... <br /> DIVISION OF LAND NUMBER.-- ----- .......... --------------- ­­ Ar4w 4Afe DATE -- <br /> ADDITIONAL COMMENTS.- <br /> ,;-. --- --- <br /> ------------------- - ----- - ---- -- ...... <br /> e-K ......... --- --- <br /> .... ------ <br /> ------ ---------------- .......... .. <br /> W............... ............... ---- - <br /> /- -- - ----- ---- -- -------- <br /> -------------------------- -7 f----- -I­.­....... <br /> ------- ------ -------------------- -------------------------I--------------- ---� <br /> ----------------------------------- ---------------- --------- <br /> VAI -- --------------- <br /> Final-Inspection. . by-..-.----- --­­ - e, .-I---------------- ------ ---Date.. <br /> J F 21677 REV.7/76 3N <br /> EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />