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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ,7— <br /> Permit No-----;7 ,------ 7� <br /> --------------------------- (Complete in Triplicate) <br /> -------------------- Doo <br /> ............ ----------­­------ This Permit Expires I Year From Date Issued FIL <br /> "�f� T-- ---- - <br /> ------------ <br /> i Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> Ordinance No, 549 and-eiisiing Rules and Regulations-. <br /> This application is made in compliance with County <br /> JOB ADDRESS/LOCATION--?. --.'.....'&_CENSUS TRACT.... .............. <br /> —.-.n........... <br /> ...... <br /> - <br /> ----------- ..;` <br /> ----------------- ....... . .......... <br /> Owner's Name.:_:__ ........ . ......... <br /> ............ <br /> ............ ................ <br /> .......... <br /> ..............License #------------ .........Phone............... .......... <br /> Contractor's Name_.......... ------------- .............. <br /> A. <br /> Install a-tio' n-will.serve: e si idence Alartment House 0 Commercial ❑ Trailer Court El <br /> M AA, <br /> ate ot*------ .............................. ...... <br /> umber of beclro�ms. -Lot Size....__ ---------- ------------------ <br /> 1 4 .,G'�rbaige Grincle-r—I------ <br /> Numbei.ofjIving units ..........1Z____N - <br /> Water Sup - Publi6 System ------------- -------- ...... ------------------------Private I rne----------- <br /> y <br /> Sand Silt❑E] Clay ❑E] Peat❑El Sandy Lopm C] . ,,Clay Loam ❑ <br /> Character of sail to a depth of 3 feet: <br /> Hardpan[I Aclobe5j* Fill Material............If yes,type.......... ........... <br /> must be placed on reverse side.}{plot plan, showing size of lot, location of-system in relation to"wells, boilclings,.etc. .0 <br /> NEW INSTA"TION.- .[No'se'ptic tank"or'seepage p•it perm.ittea if p-auiblic' sewer is ava`ilbble within 200 feet,} <br /> 4 <br /> PACKAGE-TREATMENT SEPTIC TANK- ['.I Size------- ------------------------------------------�74___-_�iquid Depth........ ------ <br /> L <br /> Compartments__--------------- ---------- <br /> Capacity--,:::-,`-----�:-------Type­_-_-!­---­----- ---- -----------------_No. <br /> .........Prop. -Line--------- -------------- <br /> Distance to nearest. Well- ....... ---------—.:Eoun <br /> ....................... ......... <br /> _each lin�eV'�' 09II'LengtO <br /> LEACHING LINE! No. of LI'nes................. .............Length of ec <br /> 'D' Box.--------j..T, pe filter Material-...................Depth Filter_(. a* ------ <br /> r10 ................... ---_--------------- <br /> Distance;to nearest: Well.:-----......................Foundati0h`.3?!`�------- ..............Property Line------------------------------------ <br /> • <br /> ine--------- ------ -------------- <br /> - +-- +- - - - . I . ..­ - I [_ t No <br /> N TmTe'r--1.1:�......... Rock Filled Yes E:) <br /> SEEPAGE PIT Depth..................Dicimoter.................... <br /> Water f'a b le-r 15 e p t h ......... Rock Size----------------------------t--------- --------- <br /> 6undatkiin_' ______--_______.._---- <br /> nearest: Well.......................... ............... ........ ----------Prop. Line <br /> ---------- <br /> -----Doti <br /> REPAIR/ADDITION (Prey:San• itation Permit#.. ... --------------------------------I• 1/_­ <br /> ...... - ------------ ------- <br /> -------- <br /> Setic Tank (Specify Reqyirements)�------------------_--- --------------------- •----------------- - ...... ---------- -T" <br /> P. r4 <br /> ................. <br /> Disposal Field (Specif Re_%UL'rement ......6:. <br /> ---- ........ ...... <br /> ---------_-- <br /> ------------- <br /> ................. --------------- ------ <br /> ---------- ----------- - --- ---- --------------- --------------------- <br /> - - - ----- ............ ------------------------------ ---------- --------•--•--- ---- ---------------- --- <br /> I <br /> (Drcmexisting and required addition on reverse side) <br /> I hereby certify lhat.1 have prepared'this'application and that the work will be done In accordan& with Sail Joaquin County <br /> Ordinances, State Laws, and Rules and, Regulations; of theSon Joaquin Local Health District. Home owner or.licensed agents <br /> s1g;atu' ro' cettitiiis' the followingi <br /> "I certify that in the performance of the Work for which this permit is-Issued, I shall not employ any person in sueh manner as <br /> to become subbiiect to 7T2n1s Compensation an laws of.CallFornla.'.'. <br /> Signed,; . .. .. ....... :Owner r <br /> . <br /> ----------------------------- <br /> ----- <br /> ----------------------- ---------------- - ----Title----------------------------- <br /> By ------- - ­--------------- <br /> - -------------------­ <br /> -------------------- <br /> (if other than owner) <br /> FOR-DEPART*ENT USE ONLY' <br /> "---. --=------------ <br /> DATE.._._. ------- <br /> APPLICATION ACCEI!11ECJ5T.-._:_..7.. DATE....... ------------- ------------------------ <br /> DIVISION OF LAND NUMBER..._- --------------------------------- <br /> ADDITIONALCOMMENTS------- --------------• - ...............R,.................................. ........ ....... ........ :...---••--------------.--------------------•- <br /> -- <br /> -­-------------------------------------------- —--------------------- ---------:..................... .......... ................................... <br /> --- ------------------------------------------------- -------------- ­�---------------- <br /> .................................................................... --- <br /> . <br /> ------------------------------- <br /> ------- ------_ <br /> ....... --------&­.-e,:. . . ..................................... <br /> Final Inspection by:------ - -----------FSS 21677 REV. 7/76 3M <br /> ER 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />