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FOR OFFICE USE: 'FOR-CiFFICE'USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................ .. ......1-9...... Permit No..2.77Z'��--7 <br /> (Complete in Triplicate) <br /> ..................................m................... <br /> Date <br /> .............................�:------ ---------- This Permit Expires I Year From Dote Issued <br /> Application is hereby made to the San.Joaquin Local'Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance.No. 549 and existing Rules and Regulations; <br /> JOB ADDRESS/LOCATION. .......61.... .. Z....... .I-------- - ......... . ... --------- -----------CENSUS TRACT"..................... <br /> ... ..... <br /> Owner's Name. -.-.... <br /> ................._ -- -----------_-------_-_-- -------- <br /> '2 e :- ----- -Phone.Z7Z- V. <br /> VIK .. _6 y............. --------------- ...zip------------- - •------- <br /> Address--- - ----- ......__................ Cit, <br /> Contractor's Name...�. ;.. Residence Apartment License ----------- Phone ----------------- <br /> Installation will serve: ❑ <br /> -------... _-' House ❑ Commercial ❑ Trailer Court <br /> Motel ❑ Other-.... ---------------------------------- IN <br /> 9 -------------:....... .... .. <br /> Number of living units:................Number of bed �Garbcige Grinder------------Lot Size <br /> e ----------------- -----.........Private <br /> Water Supply: Public System and nam .. ............. .................................................. <br /> Character of soil to a depth-of.3-f eef-­Sa-id ED— ilt'D -Clay-E] Peat F] Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material..,.... _._.If yes, type----------------------------_ - <br /> 'C4 <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage 'pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size..---_- -_--_----- ----Liquid Depth.__::-_..- _--_---_ <br /> f Capacity <br /> epth......... -------------- <br /> Capacity----------------7---Type--- '.Material--------- - -...........No. Compartments----------•---- <br /> Distance <br /> ompartrnents---------------Distance to nearest: Well---------------- - - - .'Foundation----- .. . .............Prop. Line------ ------ _-_------- <br /> LEACHING LINE No. of Lines-----------------------------Length of each line............... ------------- Total Length -- ------ ------------ <br /> 'D' Box------ - Type Filter Material........ ...:.......Depth Filter Material--:----------------.__------------------ .... .. <br /> Distance ,....-......--:..Foundation__------------------------..Property Line----_----_------....-..---.-- - _ <br /> SEEPAGE <br /> ine------------- <br /> SEEPAGE Pit Depth___1.......Diameter............. ----- Number._..___'_____-_____-______-___- Rock Filled Yes ED] No <br /> Water Table Depth.__..... ------- ----------------- ........... ----------Rock Size__....-- ---------- :..-•----- <br /> { <br /> I T' -1 1J _.........___-.--.Prop. <br /> 4 -------- -- _-- ---- <br /> Distance to nearest; Well -_----------------- ---------------Founclation. .. ...... Prop, Line,------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-------------------•--------------- ...............Date................................... ----------- <br /> - ------- ---------- --- -- ­ -------------------- <br /> Septic Tank (Specify Requirements)....-- ....................... .................. -- <br /> n :7----------- <br /> _IRequirements]:.. <br /> . ---- <br /> --------------------------------------­­...................­ ­...................................... <br /> --- ----------------- ----- <br /> Disposal Field (Specify Requireme r <br /> ts <br /> .............­-­..... ............................. -------------------­----------- ----------------------------------------------------------------- -------- ---------------- .......... ........ <br /> (1)6w existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the Son 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 WorkmanCo ensation laws of California." <br /> Signed ..__Owner <br /> By-------------------------------------------------------- ----------------------------------- ----- Title .................... ........ ------- ....... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> BY- _ - - DATE <br /> - - -- <br /> DIVISION OFLAND NUMBER'. _- ------- - -------- . <br /> --- ._.DATE. <br /> - ----- <br /> ADDITIONALCOMMENTS ..... .... ............ ------- --------------------------------------------- ................... ................ . --------- <br /> ------------------------------------------------ ----- 5....94?w .............. .......... - ------- ------------------------------------------------------------------------------------ <br /> --------------­­:. ..... __-1___ I - <br /> . ... ... ........... --------­----------- ......... ----------- -------------- ............. ........................... ........ <br /> ......... .. ...... <br /> --------------------------- --------- - - --- ---------- ----------------All... ------ --- <br /> --------------------------------------------- j <br /> ----------Dote____ _i�. . ... ......... ------ <br /> Finai lnspe:ciion ,by:_.X __ ------------ 63M <br /> F&S 21677 <br /> EH 13 24 sAP4-JbAaUI_fq­L0CAL HEALTH—DISTRICT'- <br />