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FOR OFFICE USE: FOR OFFICE USE: j <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- ------- f 1. <br /> - (Complete in Triplicate) Permit <br /> =_ - k------------ ------- <br /> --�°-~---�.. Date Issued-- --°7 .7� <br /> ------------------------ ----------------------------- -- This Permit Expires 1 Year From Date 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 /> M1" <br /> This application is made in compliance with County-Ordinance No. 549 and existing Rules and Regulations: ' <br /> O ._ 41 = _ _ CENUS.TRTJOB ADDRESS/LOCATI . [ <br /> Owner's Name. ' - --" ---- - ------ --------------------- <br /> -Phone-_g <br /> d L . . <br /> _ �� _ _ <br /> Address ' �"�"�,m .�t- .'C?-------- ------------------City- ------- Zip [ <br /> a <br /> Contractor's Name -------- ----------- ---- ----- - , -�iS --License #� _3.T_51__.-.Phone__5CO.------------------------ <br /> 'o, <br /> . �Q 7 <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> - = Motel ❑ Other-------- ------------------- <br /> 4- <br /> r <br /> Number of living units Co <br /> .. .(.- ...-.-Number af.bedrooms_.,? -_-Garbage Grinder------ -.-Lot Size_ .-x 1l�'�?_ _ <br /> Water Supply: Public System and name i _-. -------------------------- -_-__:_____ _ <br /> -- _-_ ___--_. -----------------------Private <br /> Character of soil to a depth of 3 feet: Sand Q It❑'Clay ❑'�.R a ❑ Sandy Loam ❑ Clay Loam ❑ <br /> I _ <br /> -Hardpan ❑ Adobe Fill Material -....._-__';f yes, type------------------- ------------ ; <br /> (Plot plan, showing size of lot,'locationof system in relation to'wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: E(No septic tankror.seepage pit permitted if public sewer is available within 200 feet,) �t <br /> �.. <br /> PACKAGE TREATMENT [ ) SEPTIC TANK � 4 - SizeT" _ __.Liquid Depth_._-$Y--...._Ca __ <br /> P Y- � Type - Material- ------No. Compartments------- <br /> t _ f . / _ t f t7 Jed- <br /> i Distance o=nearest:Well-___ Q_ --'Foundation <br /> ,.�3�!�� I ? �• F, - -- -- -{-�. � --=---�------ Prop. Line----- ---------------- <br /> IG <br /> - --- --- <br /> - - - ----- - - <br /> s . <br /> LEACiING LINE Na. of --------'---..:`.......Length o each line Total Length _./7a �.._..._ _ __ <br /> D' Box------ .. Type Filter Nlatenal:....(F-,f7i'ti._.Depth Filter Materaal........._l_ --- ------------- _ . _________a__.. <br /> . ...._ 1 <br /> ! `""'` Distance to nearest: Well_._f��_f�-------Foundation _4 �b tom-.... ....Property Line __4�_..- ._ <br /> SEEPAGE PIT',% Depth-25 Diameter ___' _��__-Number--------- �.......... h ' Rock Filled,,,Yes� No ❑ � <br /> Water Table Depth.--;-. .. - --- ---Rock .Siie.. ! 1-�1------ - 4 <br /> ' nearest: Weli......1�d__. ,__._ _ _._ � ` <br /> ....Q <br /> [ ; <br /> F nda -- <br /> Distanced <br /> � -; --- o tion <br /> REPAIR/ADDITION (Prev',. Sanitation Permit#'_...:. Date____________ __ ; <br /> yf._..___.... "._____�___.____ <br /> Septic Tank (Specify Requirements)- ,- - = = 1 -: <br /> Disposal Field(Specify Requirements)-------------------------- ---- =-_z` r -- ---- --------------- ---------------.---------- --------- i <br /> h �°., , <br /> ---------------------------------------------------- --- -------- -- -- -- <br /> I. 'CJ'(lDrdw,�existing and required addition 'on reverse side) i <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 San Joaquin Local Heal th,D istri tt. Home owner or licensed agents <br /> signature certifies the followings <br /> � <br /> ,� + f <br /> - I certify that in th-e performance 'of the work for which this permlf is issued;I shall not employ any person in such nignner as <br /> to become-subject to.Workman's Compensation laws of California." <br /> Signed --- �OWner r #` <br /> BY /� .�/-..--- =----- - -------------------- Titley ------- - T ; <br /> g .. . .. - - `- .. _ <br /> (I 'other than owner) t . {..�-.. ,F + <br /> FO <br /> R DEPARTMENT USE ONLY'_'!' ` <br /> APPLICATION ACCEPTED $Y. - -- :- tom..--- , <br /> _ ...... -� y <br /> DIVISION OF LAND NUMBER.----- ------ ---- ='.". - c-. DATE <br /> ADDITIONALCOMMENTS-------------------------------------------- -------------------------------------------- -- --------------------- <br /> -------------- --- -------------------------- t <br /> - ----- ---------------------------------------------------------------- <br /> �, -7$ '-. �►� p �- -- ---------------------------------------------- <br /> ----------------- ----- <br /> --------------- - ------------------ --- - --- � ---- <br /> Final Inspection b 7�1- -------- y .-J 17 <br /> P Y -.. Date. . <br /> EH 13 24 " SAN-JOAQUINCOGAL-HEALTH DISTRICT <br /> F&5 21677 REV. 7/76 3M <br /> F <br />