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FOR OFFICE USE: I <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> r t <br /> No...... <br /> Permit ......... <br /> "i <br /> ---------- - ---- --- - --- ------------- <br /> (Complete in Triplicate) <br /> I ss <br /> Datesue&0'1---- <br /> ------ Is <br /> This Permit Expires 1 Year From Date issued <br /> Application is hereby made to the San Joaquin Local andinstallthe work herein described. <br /> Health District for � permit to"construct'a <br /> This application is made in compliance,-W' ith County.Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --- <br /> . - _ ( I ----------------- ---- <br /> ------ <br /> ---- -- ---- -- --- TRACT_ . .......... ........ <br /> ....Phone ------ --------- <br /> Owner's Name.... 7- <br /> Cit <br /> Address--- ... ..... <br /> License Phone- <br /> Controctor�s Name.......__ �;.�Jnl� ...... Lice <br /> Installation will serve: 617-71 Residence R Apartment House F� Commercial [] Trailer' Court C] <br /> Motel ❑ Other.._.-- --- ----------------------------- <br /> ....6..0. .............. .. .. <br /> _--Garbage-Grinclef —_—..-Lot Size6 <br /> Number of living units: ....'_.__..._Number bf'bedr6oms_'- Private El <br /> -------------------- <br /> ---- ------- ------- ------ ------ - ------- <br /> .... ............ <br /> Water Supply: Public System and namel <br /> . _---------F_- <br /> Sand [:) ❑Silt D Clay -Peat Ll Sandy ❑Loam E3 Clay Loam <br /> Character of soil to a depth of 3 feet: �( I <br /> i Fill Material` . . if-yes, type---------- <br /> Hardpan Adobe n ----------------- - -- <br /> of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> JPlot plan, showing size of lot, location <br /> .1 available within 200 feet,} <br /> NEW INSTALLATION: (No 'septic tank or seepage pit permitted if public sewer is I <br /> A Size....__. .._.... ------------------- ----Liquid Depth.---Ll------ ---_------1111 <br /> PACKAGE TREATMENT SEPTIC TANK [ I : - <br /> Capacity-/. i I Compartments�----9�1•----------- -------------N <br /> ---Type---,*------ --- - --- ---------No. <br /> Well.. ............Founclatio' _...Prop. Line----/?------- ------------- <br /> Distance to nearest. <br /> — I --Total Length <br /> -------- Length of eac hne�.__7_40------------ <br /> LEACHING LINE No. of Lines ...... <br /> erial. .11-------------- ............... .............. <br /> Filter Material--- .--..Depth Filter Mat <br /> 'D' Box <br /> I I YFc --------------� ..Property Line----•--------------------------- <br /> Distanc&to nearest: Well----------------- -------- <br /> - IRock Filled Yes No C] <br /> Diameter--- - -------Number.....----17 <br /> SEEPAGE PIT Depth.. 17f, Rock Size_ ........ ......... ------ ---- <br /> Water Table.,Depth----------_------ ----------------- <br /> Prop, Line_.------------- <br /> Distance to nearest: . . ..... <br /> I rmit#------------------------- ---- ---------------Dote------------------ --- --- ----- - ------------ <br /> REPAIR/ADDITION (Prev, Sanitation Pe .............. ------ <br /> I ..,............ . ....... ....­------- ---------7------- ----- --------- --------------------- <br /> Septic Tank (Specify Requirements)--- --------- <br /> ----------------------- ----------------- --------­­- ------------• --- .......... ...... <br /> Disposal Field (Specify Requirements)f-_---------------- <br /> --------------- ------ --------------------------- -- ------- ...... -----------­­........ <br /> --------------------------------------- ----------- <br /> --------------- ---- -------- ... ... - --------- ------- ---- --- ----ng and r eq aired ed a d d i ti on ori reverse <br /> (Draw exist! side) ith Son Joaquin County <br /> he work will he done in accordance w <br /> I hereby certify that I have prepared,I this application and that I Son Joaquin Local Health District. Home owner or licensed agents <br /> Ordinances, State Laws and Rules and Regulations of the <br /> signature certifies the following: employ any person in such manner as <br /> .11 certify that in the performance of the work for which this permit is issued, I shall not e <br /> to become subject to Wdrkman's Compensation laws Of California." <br /> ....Owner <br /> .............. . --- - ------- <br /> Signecl -------7- ----- ------- ------ ........ <br /> By.......... . - )_ - --- - -1 �- -- ---- -- ---- <br /> lit other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE ..... ..................... ....... <br /> ----------- ----- --------- ------- . ...... <br /> APPLICATION ACCEPTED <br /> ------ ------- - -------- -------- <br /> DIVISION OF LAND NUMBER -_1... ...... ------•--- --- ............v------ Ae�v <br /> 1�rv/w4z.............. r ...........:V­ .- . ..... ------------ <br /> ADDITIONAL COMMENTS. aw- ....... ........... ... <br /> I --------- .......­___......I-----------I............I........... <br /> .................-........ ............ .. ....I I i.._,.._------------------------ --_------------__------------------------- --------------------------------- -------------- ---------------- -------- - <br /> ---------------------------------- --------- -------:1 A..iAr------------ ......... <br /> -------------------------- ------ -------------------------------------------------- -------- . .......I—---- ----- <br /> ...... --------- ----- <br /> 7............. &,D .,r Date_­ <br /> Final Inspd6ion by:............. ....... ........ - ------- ---------- F&S 21677 REV. 7176 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />