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- -` FOR OFFICE USE: ` <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No._.� <br /> . (Complete in Triplicate) <br /> Date Issued-._---� <br /> -----------------------­----I------ --------q ) <br /> This Permit Expires 1 Year From Date Issued <br /> Health District for a permit to construct and install the work herein described. <br /> Application is hereby made to the San Joaquin Local <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> F _ __________- .___-___._________.___.---__._. Y <br /> l � r ' C NSIJS.TRACT <br /> JOB ADDRESS/LOCATION G��.- _ -- ---------- -- ----- - <br /> _. <br /> Owner's Name - = l <br /> Ph ne. "_ --------------- <br /> �.,�_t City_. -- -- -- - - ----------- Zip_ <br /> --- --- <br /> :. _ <br /> Address /lF-�f-. ------._ � - ----- <br /> . _ ------ =------- - -=- ---License #_P.�_���-3_�_ <br /> Contractor's Name------ -- v <br /> installation will serve: Residence ❑ Apartment House[I Commercial Trailer Court ❑ <br /> t -_" .Garbo e Grinder____- Lot <br /> k � ....�F-Motel <br /> i --._ Size -------° ---- ---- -- -=- ------ - ------ --- ----z--- <br /> Number of living units.:----�.---Nun•?ber off..be'drooms__� J 1 <br /> t " - <br /> private X* <br /> Water Supply: Public System and name--- <br /> Character of soil to a depth of 3 feet: ; Sand [ISilt❑ Clay ❑ Peat❑ Sandy Loam El Clay Loam"❑ <br /> ,. <br /> " <br /> Adobe Fill Material - ---- --- ---- <br /> (f Yes, type ------------- ---- --- �.-- <br /> L Hardpan ❑ -� : � , <br /> (Plot plan, showing size of lot, location of system in relation to wells, <br /> buildings, etc. must be placed 0n reverse side.) A <br /> _. _.... r <br /> NEW INSTALLATION: (Na septic tank-or seepage pit permitted if public sewer is available within 200 feet,) / <br /> �,R: .«.�,,,., -L/�� - Liquid Depth.__--- N . <br /> SEPTIC TANK-LLY' _ ` <br /> Size---- - ---- -- --•- <br /> PACKAGE TREATMENT L lm s -----__"-_a - ------ <br /> 4rMaterial___ __::__,­No. art ent _ <br /> CapaatY-�1 ?-- 'TYPe 'Q-�, _ . <br /> :.." .- <br /> Foundation Comp ----Prop. Line_.: ""�_" ' <br /> Distance.to nearest:.Well-:-__ <br /> No. of Lines..;, � - ------ <br /> -.;Length each�line--.4 .---- � 9�.:- .7 <br /> Total - <br /> LEACHING UNE [+�1 ----- <br /> D' Box__'&< -Type Filter Materia': c Or* .beptl Filter Material_ i . <br /> // Pro er Line `- <br /> -___-Foundation_)-�-°-- P tY F <br /> Distance to nearest: Wel1.__ ti�d Y-� N <br /> SEEPAGE PIT CL`T Depth_ -•• _.Diameter 3-� �Nu�ber=_._ _ ------------------------ <br /> PIT <br /> -:_ -§- -- <br /> �(Rock Filled Yes o <br /> . ," ; / .Rock Size--- <br /> ��--3- - --- -- - --- <br /> } f .HcWater Table Depth__" iQ� �- �• <br /> Distance to�nearest: Well ------------ <br /> - ------_.Foundation_____. -- <br /> --------.Pro Line--- <br /> f — p• <br /> ' ---Date---- ------ ------------------------------ <br /> ----- -------- ------ --- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_-_ -ti------------- ----------------- <br /> ------------ ------------- <br /> Septic Tank (Specify Requirements)--,---- .--_`"-.: •--- --------------------------" <br /> -------------------- <br /> ------------------------- -- --------------- - <br /> Disposal Field- (Specify Requirements)i.-_____'�..__._-- --- -------------- ---- --- - - <br /> ''`. ----------------------- --- -. ---------- <br /> - - <br /> = --------- --- <br /> 4-4- - - --- ------------------------------ - - <br /> ------ ----------- ------------------------------------- ------ <br /> --------- - <br /> ------- - -------------=---- = = <br /> t(Draw existing and requ" ired addition on reverse side) <br /> I hereby certify that 1 have prepared this pplication and that the work'wi-Ii. aldHealth Distrone in ict. Home ownance with <br /> Ordinances, <br /> orJli licensed agenoaquin ts <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin <br /> s <br /> signature certi0h;s the following: person in such manner as <br /> 9`1 certify that in the performance of 4he work for which this permit is issued, I shall not employ any <br /> to beta e u jec to Wo n mpensation laws .of .California." <br /> Signed = = <br /> T --------------- --------------- <br /> -. <br /> _ �• x -�- <br /> of"ofher Phan ow er) <br /> ' 'F DEP RTMENT'USE'ONLY '" { ` <br /> ' <br /> APPLICATION ACCEPTED SY".. DATE- ----- � � - - -- -- - <br /> _.. _.. <br /> -- l __`----- ------ ----- - ----- - -- -- <br /> DATE.. - - --- <br /> DIVISION OF LAND NUMBER----------------------------- ---- -- <br /> ----- ---- <br /> � _._d Zg---------- <br /> -----------=--------------- - <br /> ADDITIONAL COMMENTS--------- - <br /> ---------------------- ----------------------------------------------- <br /> ------------. -.. <br /> Date ------------ <br /> Final Inspection b <br /> ----------------- <br /> ----------- <br /> ------------- <br /> y:-=-----•- �`--- - /7 F&S 21677 REV, 7/76 3M <br /> EH I.3 24 SAN JOA UIN LOCAL HEALTH DISTRICT <br />