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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLI ATI FOR SANITAT N PERMIT <br /> .7G <br /> ---- ----- -------- ------ --- Permit No.-- 70__� <br /> - - <br /> (Complete in Triplicate} <br /> ----- --- f-- ---------------- ----------- <br /> .Date Issued----�------ - <br /> ------ ------------------- This Permit Expires 1 Year From Date issued <br /> i <br /> A lication is hereb made to the San Joaquin Local Health District for a permit t-constrluct and instali-the.work herein described. i <br /> Thiss application is made in compliance with County Ordinance No. 549 and existing Rules and'Regul'atlons: <br /> �n CENSUS TRACT----------- - ----------------- <br /> JOB ADDRESS/LO-C�ATITION ----------- �C-_-- -Y./. <br /> Owner's Name.---N- Phone <br /> F <br /> . CitY ; : zip -- <br /> -------------- - -----------------Address <br /> License Phone-- - <br /> D� -- <br /> Contractor's Name------- <br /> 1 Installation will:serve: Residence Apartment House.❑ Commercial ❑ Trailer Court. ❑ <br /> I y tel ❑- =other-------------------t----------= - ------- ! t <br /> Number of living.units:.______-------Number of bedroom --- G bage Grinder___-- -._-_Lot Size_ -_.--_ __._.______________ .:_.- <br /> I 1 <br /> I Water 5u I Public System and name------------------- -- - ------ Private ,Q <br /> Supp Y - - ! o <br /> ti T <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ 5andy Loam ❑ Clay Loam ❑' <br /> 4 Hardpan ❑ Adobe❑ Fill Material-- --------If yes, type-_._.--_____.-_.--E----------- <br /> (Plot plan, showing size of lot, location of system in relation to,wells, buildings, etc. must be pl".aced on reverse side.) l <br /> I <br /> NEW INSTALLATION: (No.septic tank or seepage pit permitted if public sewer is available within 200 feet,) j G <br /> PACKAGE TREATMENT '[ ] j'SEPTIC TANK [ ] Size--------------------------------------- <br /> `- ---Liquid Depth..-- --------'----------- <br /> i <br /> Capa : i---- ---T YP e------------- =--------Material-------------- ==---:-No. Compartments.-------- --1--,-----_ ---- <br /> t , P- Y-=-=--- <br /> t ..Distance.to nearest: Well-------- „-----------------------Foundation-------------_- -.---------Prop. Line- --------------------- --- <br /> ------ <br /> -- <br /> LEACHING LINE [.]._ No. of Lines _ ----.Length of each line. ----- -------------- <br /> ------------------ <br /> 'D' <br /> Total Length---------- -` ^�1-k------------------ <br /> ---------- <br /> 1 'D' Box------------.Type Filter Material :-_ -_____pepth Filter Material__ ------------------------------------ , - <br /> 1 F_ <br /> [ 'Distances to nearest: Well-:---_------------------ --Foundation------------------------_---Property Line.--.--_ ----- ------ ---- --- <br /> T­ <br /> Rock Filled Y�s F No E] <br /> SEEPAGE <br /> ---- <br /> SEEPAGE PIT [ ] Depth---- -----------Diameter_ ------------- er:----------------`--------------- Rock Filled Yes ❑ No ❑ <br /> Numb <br /> I } Water Table Depth ---------;------------------------------ ---- .. t_ �• P ------L Line---- -j l <br /> Rock Size .--:------- <br /> i 1 --- --- -- ------- <br /> Distance tc nearest: Well----------------- :_:.----_-_____kFounda ion.. rop, i <br /> REPAIR/ADDITION (Prev. San ------ EDate.----------------------------------------------- <br /> Septic <br /> ------ - ------- <br /> i station Permit# : -----�---==-- �------:--- -- ---�j ---------"� --:---- : <br /> Septic Tank(Specify Requirements)- - -- -- ------------- <br /> -- <br /> Field (Specify.Requirements)= Q - - ---- --------- <br /> Disposal --------------------------- <br /> 1 <br /> ----•-------- <br /> ----- - ------------- - ----- - :: <br /> - ---------------- <br /> ------------- <br /> ----------------------------- --- --------- - <br /> ---= - -- --- - <br /> S --= �--- -- ---1--- ' <br /> -- ------- ---------------- ------------------------------- ------ ------=---------------------- = , <br /> ' (Draw existing and required addifion yan reverse side) <br /> I hereby certify that I have prepared this application and that the work will be-done•in-accordance with Sari Joaquin County <br /> Ordinances, State Laws; and Rules.and Regulations of the San Joaquin Local Health District Home owner or ficensed agents <br /> signature certifies the following: Y if <br /> "i certify that in the performance"of the work'for which this permit is issued, ,I shall not employ any person in such manneras <br /> to become subject to Workman'sCompensation Taws of California." ( E � * # <br /> Signed : <br /> ------------ <br /> ---_ - .-.--Owner , <br /> ---- - - -- <br /> .0 t <br /> Title-----=--- <br /> �( f' <br /> oth r than .owner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -__ : a C�1 -- ------=--------------------------- --------------------:----- -- ----- <br /> DIVISION OF LAND NUMBER: <br /> DATE----�= -a : --------------------- <br /> ---- <br /> -�------------ <br /> . .. _ <br /> ADDITIONAL COMMENTS----- - -------------- ` '�------.---- t------ ---- ------------ <br /> --- ------ - -- ------ <br /> ----=------- -------- - -- - -------- <br /> ----- --- ----------- --- -------------- <br /> i ------- -- ------------------ - ------ -------- ----- --:.------------ <br /> -------•--- <br /> - �. <br /> -- <br /> ---------------------- ------ ---------------- ----------------------------- .---------------------------------- --- <br /> Final Inspection-by: �_- ,.r:.A. �v ._ -------Date------ .- �� <br /> ------.-- <br /> =--- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />