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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .................... -------------------- Permit No.7f�,114?7-- <br /> (Complete in Triplicate) <br /> --•------------------------------- - . ....... ' <br /> Date I�su6 <br /> d ':n) 5r <br /> ................................... ........ This Peim'it Expires I Year From Date Issued V <br /> Application is hereby made to.the Son Joaquin Local Health District for a perm'it 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 /> .3v_t�. <br /> 9- --------------- ---------------ENSUS TRACT------- ----------- - <br />-JOB ADDRESS/LOCATIO�!�L .... -- - - <br /> ----------- -------- ... ..... . <br /> ----------- --- ........ <br /> .......... ............I <br /> Owner's Name........ .... .. .. ------------Phone-.-........... <br /> .... . - ---------- <br /> Address.... ... ......... ----------------­-- --- cit,. Com(. ,Zip -- <br /> . . <br /> Contractor's Name....... ................. ...... ..............License Phone,?5�.............. ----------- <br /> Alp <br /> Installation will serve: Residence /Apartment House E] Commercial E] Trailer Court Ej <br /> Motel E] ' Other--- ..... .. ..._----- ----------_....... <br /> .. ....... .. <br /> Number of living units: ...... Number of bedrooms. ... Garbage Grind a%s---Lot Size/- . <br /> L <br /> -------Private <br /> Water Supply.. Public System and name---------------------- ------ ........................ ------ ------ --------------------- --------- <br /> Character of soil to a depth.of 3 feet: Sand E] SjiltA�Clay 0 Peat E] Sandy Loam E] Clay Loom 0 <br /> Hardpan Ej Adobe P,,-Fill Material ... ... If yes, type..-.------_------------- - <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 200feetj <br /> PACKAGE TREATMENT SEPTIC TANK Size ---------- -- ------ <br /> -- - Liquid Depth. . ...... <br /> Capacity......................Type--------- ............ -------------------- -----No. Compartment''s--------- ------- ...... <br /> Distance to nearest: .......... ..,Foundation'.......... . .... . ..Prop. Line-_,.:, <br /> ....... ....... <br /> _­�:"Total'rength L........... ............ <br /> LEACHING LINE No. of Lines............ .......... 1ength of each line....:..._:.... ....... <br /> --------------- ............. . ---------------- <br /> 'D' Box ....Type Filter Material. ...Y....._Depth Filter Material- <br /> Distance to nearest: Well------------------------ ---Foundation-------- ------------------ Property Line..._.....-_-- ------ <br /> SEEPAGE PIT Depth.. ............Diam6ter------------- ---Number-------------------------------- Rock Filled Yes El No <br /> Water Table Depth.-•- ------------------------ ----------------Rock Size.- ----- - ------- <br /> We <br /> Distance to nearest; Foundation.............. .......... Prop., Line._ ...-------- <br /> -------- ----------------- ------ - <br /> REPAIR/ADDITION (Prev, Sanitation Permit#- ------- _Date Date---------•-------------------------- ----- <br /> ......... ............ <br /> Septic Tank (Specify Requirements)--------- ------ -------- -------- ---------------------------------------- ------------- - ------ -- -------- <br /> -X. . ..... ------- ------­-------- <br /> Disposal Field {Specify Requirements]_........-t/-- -0-- ,.,. <br /> , <br /> ----------­ <br /> ------------ ­ <br /> ------- -------------- -------------- --------------- <br /> -----------�- <br /> .. . .... -------- ----- ---------------------------------------- ---- ..................­­----------------- ...... 3 ---- ----------- ............... <br /> (Draw existing and required addition on reverse sicle♦ <br /> I hereby certify t6at. 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. HoM6 owner or licensed agents <br /> signature certifies the following: rF <br /> "I certify that in the performance of.th6 work foe-which this permit is issued, I shall not employ any person in such manner as <br /> to become sublect to r9ans C Pe7safion laws of California." <br /> Signed-------- ...... -----...----Owner <br /> ------------ ....... ---------------- <br /> By------------ ...... e..... ....... ------------- ------- ..........Title..._%-—----------- <br /> ------------------- <br /> (If 'other than ownerl' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION,ACCEPTED BY------ . ................ ............ ------- -------------- ------------ ------ D AT E--x41.1zn.. <br /> ...... ------------ - ---- ------ ---- <br /> DIVISION OF LAND NUMBER.----- --K... ..... ... DATE... <br /> ADDITIONALCOMMENTS ­ .............. -------------­---­-------------_............................. ........ ........... ..­­...... <br /> ­ -------------- .....................:------------------------ ------ -- ­ - -- <br /> -----------_.................... ....... ... . --- ---------------- - ................. .........­--------- ---------------------------------------------- ------- ---- <br /> ........... .... . ..... <br /> ------- .................. - ----------------------------------- <br /> ----------­.­_-------------------- <br /> ---------- --------------- ---- --- ----------------- ------------------------------ ------------------------------ - <br /> e:cimn by:-------1� <br /> Final Insp --------------- -- -- .........m.......... ------------.Date...- F&S 21677 REV. 7/76 3M <br /> EH 13 24 Y SAN JOAQUIN LOCALHEALTH DISTRICT L <br />