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Y , ¢( FOR OFFICE USE: <br /> FOR OFFICE USE: t%" AppLICATIOWFOR SANITATION PERMIT , <br /> Permit <br /> ----------------- -------------- <br /> ------------ Triplicate) <br /> (Complete +n . <br /> Date Issued__8'--/S'1- <br /> This Permit Expires 1 Year From Date Issued <br /> work herein described. <br /> Application is hereby made to the San Joaquin Local <br /> Health DisNo.trict for a d ex strmit.to consRultes anruct d Regulations: <br /> This application is made in compliance with County <br /> - <br /> CENSUS TRACT <br /> u-- ----- 1�- <br /> � - - <br /> JOB ADDRESS/LOCATION •.�-�- -- - - --------- ----- -- -- - ------------------------ ------------- <br /> Phone- :. " <br /> ,- <br /> s � <br /> Owner s Name- : = <br /> - (� - ----_-- Zip---: <br /> �_�. <br /> Address--------- ----- - - :.y_f -- ------ - <br /> Contractor's._Name---- <br /> �- Phone-- ------ ------ -- <br /> Installation will serve: : Residence [� Apartment House.❑ Commercial ❑ Trailer Court El <br /> G i Motel Other----!-------------- - --- ---- ---------- = <br /> ��-.--.Garbage Grinder Lot Size - _ <br /> ------ <br /> Number of livingunitsa-.____-1-___-__Number of.bedrooms.. Private <br /> i <br /> _ <br /> - --------------------- <br /> Water Supply: Public System and name-------------.------- ------------ _----- Sand Laam ❑ Clay Loam ❑ <br /> i Silt PayPeat ❑ Y <br /> Character of soil to a depth of 3 feet:/ Sand ❑ ❑ ❑ <br /> I Hardpan Adobe❑ ? Fill Material------------If yes, type <br /> erse <br /> Plot plan, showing size of lot, location of system in relation to'wells,,buildings, etc.'must <br /> be placed <br /> lace hon rev feet side.) <br /> p 1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted �f public sewer 1 I p h <br /> -. ---------------------- <br /> ------------------ <br /> PACKAGE <br /> ----- Liquid Det <br /> SEPTIC TAMC _1..�.,,�- -----�-� <br /> PACKAGE�TREATMENT "L j N-- —i --No. Compartments_------------------------------- <br /> ------------ <br /> --- ------ --------------- <br /> �CapacitY :.___.-- Type-- -------------�- Matexial_W----- ------ p <br /> I T e <br /> YFoundation----------------- --: Prop. Line <br /> tDistance to nearest Tell---^�=-" <br /> otal Length.------------------- '" <br /> LEACHING LINE. .[ l :No, of Lines-------'---------------------Length of eachclina----------------- ---------T -- - - -- # <br /> -------TY,pe Filter Material---- - .-.-.Depth Filter Material- ----------------- ----------- <br /> - D' Box-----. -Y�---- <br /> - <br /> ---- -------- ------------- <br /> -------------- <br /> Property LinQ <br /> estWell-=-------------=------------Foundation-___._------- <br /> Distanceto nearRock Filled Yes.❑ <br /> No ❑ <br /> r � Number ------- ----- ---- <br /> SEEPAGE PIT Depth----------------Diameter. <br /> -. Size- --- ------ ------ ------ <br /> Water Table Depth --------------------------------t---------- - ------- ----- ---- " <br /> Distance to nearest: Well---------- -------------- ---- <br /> Foundation_-_.___--------- <br /> ---- Prop. Line-- ---- ------ ---- <br /> t ---- -Date------- ----------- ? <br /> REPAIR/ADDITION (Prev. Sanitation Permitt#--------=----------- " 1 �. <br /> - -`4-'--------------- ----------__---------------`-----------------------'-'------------------------- <br /> Septic Tank (Specify Requirements)__--._._.-- -----=---------- i-m � <br /> �,' "`"----------------------------------- ----- <br /> Disposal Field (Specify Requ+rem nts)----- ---- - r _ ^� ------ - -- - ---------------------- <br /> ------------------------ _ -- <br /> = - ----- <br /> ----------------- <br /> ( �-- s <br /> --•-=--- --------------------- ;: r <br /> (Draw existing-and "addition reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be ldone in accor" ce with Son Health District. Home owner orJoaquin li licensed agents <br /> Y <br /> Ordinances, State Laws, and Rules and R4gulations of the- San Joaquin Local <br /> signature certifies the following: arson in such manner as <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any p <br /> to become subject. to Workman's Compensation laws of California." <br /> OW r <br /> n&r <br /> Signed----------------------------------------------- <br /> ------------------------ --------- ' --------------------- <br /> ------------------------------------- <br /> T <br /> - <br /> (if other than owner) <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> ` -"---- ---.> <br /> DATE / 7­ <br /> -------- <br /> ff <br /> APPLICATION ACCEPTED BY ___--- -- <br /> DIVISION OF LAND NUMBER -------------- ------ - -- <br /> ------------ <br /> - ---------------- -- <br /> ADDITIONALCOMMENTS-- --- ----_---------------- ---- ---- - - -- - ----- ----- ----- ------- ------ <br /> ----------------- --------------- ------ ---- <br /> ----------------- ---- Date---- ----- <br /> ------------------ <br /> P; <br /> - - ------ -, <br /> Final Inspection by:---=-^ �"' <br /> --- -�- - � ------ - F&S 21677 REV. 7/76; <br /> �N is sa SAN JOAQUIN LOCAL HEALTH DISTRICT <br />