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FOR QI`FICL U6t:; <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit N o"? v <br /> ----------------- ----- ....... .. ............... ... (Complete in Triplicate) <br /> .........­-------------- Date Issued 4 <br /> This Permit Expires I Year From Date Issued <br /> .............. ...................... <br /> 1! <br /> -1 2�,,� ; . <br /> Applicati6 "..is-hereby­macle to.theSan Joquin Local Health District for a permit to construct and.install the work herein described <br /> , with County Ordinance No. 549 and existing Rules and Regulations; <br /> This application is made in cornpliant P <br /> 4)6" <br /> JOB ADDRESS/LOCATION ... .......... <br /> 27I. <br /> Owner's Name.... .... ... ....... Phone.10._ <br /> Zip-------- ------1-............. <br /> City --------- --------------- <br /> Address_----- ------- 41611" .- <br /> ---------- -------- Phone.V'�44p4(­11... <br /> Contractor's Name......... ------ -___....... License <br /> ' <br /> Installation will serve: Residence E] Apartment HouseE] Commeircial-F❑] Trailer Court El <br /> Motel J-17 <br /> Number of living units:... -------Number of bedrooms..../__ Garbage Grinder------------Lot Size---------------...._ -- ---------•z........... .... <br /> Water Supply. Public System and name.-, .-Sand E] Silt Clay E] Pea-------- ---- --- ------ t Sandy Loam----------------------- ---------------- ........ --------- --------Private-----Clay Loam El <br /> Character of soil to a depth of 3 feet: X <br /> Hardpan E] Adobe E] Fill Material.. ... ....if yes, type--------------•---- <br /> I <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) i. <br /> NEW INSTALLATION: (No septic tank or seepage 'pit permitted if public sewer is available within 200 feet,) <br /> Size id Depth.'�/... <br /> t�o ...I—......Liquid PACKAGE TREATMENT SEPTIC TANK ....... . ............ -------- ------- <br /> Material ------------No. Compartments -----02----------- ------- <br /> Ccipacityj.�._O..O-----Type 4T <br /> 'Foundation..-' <br /> Distance to nearest.. Well.- ------- _0k..eA A., <br /> Qw, �...Prop. Line. <br /> - -_------------ <br /> LEACHING LINE No. of Lines --------- ---------- Length of each line....._...__-------------- ---Total Length <br /> 'D' Box............Type Filter Material------ ........Depth Filter Material.. ........ ----------­- --------------- ---- -------- <br /> Property Line....-----•------ <br /> Distance to nearest: Well..................... -"".Foundation..---------------------- <br /> SEEPAGE PIT Depth.....---.- -Diameter------------_------Number.- .--------------------------- Rock F I il.led Yes El No <br /> WaterTable Depth------------ ---------- ........ ............. ----.Rock Size---- .... ........ ------ --------------------- <br /> Distance to nearest: Well-----------------"---.... ----"- ------ Foundation...-_-------...- _"--...".Prop. Line..----------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit ----- --- ..........D te ------ <br /> Septic Tank (Specify Requirementsl .............. <br /> Disposal Field (Specify Requirements)., ............. -------------- ------------------ ------------ IL <br /> ---------------- ----------------- ..... .......... ............ .......... ......... <br /> ------------- ........ ---------------------- ----------------------------- <br /> {Draw existing and required addition on reverse side) <br /> ---------------- ------------------------------ ------ --------------- ------------ --I- --- ---------------- ------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count, <br /> Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed ag6nb <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 )*--W, k Compensation laws of California." <br /> or, m7as Owner <br /> Signed------- ---- <br /> ----.Title.- --- <br /> By............................. ........... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> *�777 ..... .......... <br /> APPLICATION ACCEPTED BY-:-- - ----- -----------­--------- --------- <br /> ---------------- ------- ............. --------_---------------------- ........... DATE.----- - --------_ ----------- -­ .......... <br /> DIVISION OF LAND NUMBER... <br /> ---------- --- ------------- ------ ------------------ <br /> ADDITIONAL COMMENTS.. <br /> ------------`--.COMMEN.........T....S<..I._!-.-:.-.--.-..-..-..-.-L.--.--.--.--.--. <br /> ................... --..--.-.--.­--.1-----1--1-.--.----.­-.-.--.--.--.--.--.--.--.--.--.--.--.--.--.--.--.--.-.-.-..-.-.--.---..-----.---.-- ------------------•---------------•----- <br /> ------.--------------------------------_--.--.---.---.--- <br /> .--.----.--.--.--.--.--.---.--.--.---.-.---­------------------------------.--.--.--.--.--.--.-.--.--.--.--.-- <br /> ---------------.---.--.-.--.--.--.--.- <br /> . - ------ - ---- -Date � ....74-.--.--.-.7.-..-.-.?-.-- <br /> .--..-..--..--.--..-.- <br /> ........ <br /> ---..-.-.- <br /> Final Inspection by ...... <br /> F&S 21677 REV. 7/76 3M <br /> EH 13 44 fAtIJOAQUIN LOCAL HEALTH DISTRICT <br />