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` FOR OFFICE USE;
<br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE;
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<br /> (Complete in Triplicate) Permit ,�
<br /> No._77"-3��
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<br /> --------------------- -=------------------------- This Permit Expires 1 Year From Date Issued 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 /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: T
<br /> JOB ADDRESS/LOCATI Obi ----------
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<br /> CENSUS.TRACT-------------------
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<br /> Owner' Name------- - ---- -Phone.--- ---- --
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<br /> . 4 - _- _ _ �-
<br /> 2G_ J-4----
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<br /> City - i
<br /> Contractor sf Name--_--- �.�_� ----- �_Zc -- --------------License #, -- - ---- - --0- --Phone- �-
<br /> Installation will 'serve,. Residence-, Apartment House.❑ :Commercial ❑ Trailer Court ❑
<br /> Motel•❑•- k
<br /> Other__ �. ._--
<br /> - 7
<br /> Numfber of living units:_._ _. ------Number.of,besdrooms ,;Z- _Garbage Grinder.__ Lot'Size
<br /> t'�,-
<br /> Water Supply: Public System and name__.._-. - :_�Q ,,,�,,,,
<br /> ._. /. .. --- -._ Private
<br /> Character of soil to a depth of 3 feet: ` Sand ❑ Silt El 'Clay Peat❑ "Sand" Loam ❑ - lay Loam
<br /> # Hardpan ❑ Adobe ❑ . Fill Material--.---------if yes, type-•-='------------------- -
<br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. mustbe paced on reverse side.)
<br /> r - .L - + U
<br /> NEW 'INSTALLATION.- (No'septic tank �or seepage .pit permittted if public sewer is available,.within 200 feet,} �
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<br /> PACKAGE TREATMENT [ ] . SEPTIC TANK
<br /> C ] Size --AZ 0- - -- =l -- -Liqu i
<br /> -- d
<br /> l YCapacity, ava_ ype_ .
<br /> Depth._
<br /> Compartments_ r__.___�-__
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<br /> Distanceto nearest: Well_ __" 7 ` Prop.,Line "Qj
<br /> r �f � •,•- l � r
<br /> LEACHING LINE, [ ] No, of Lines-,-_____i _ Len '
<br /> o -` g'th.af��ch line.--------- - Total Length. P� ----------
<br /> Iter
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<br /> ' D' Box__'_ Ty G �i � E
<br /> pe Filter Material_ _ _ 1? e th Filter Mal real __._f ----------
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<br /> Distance
<br /> _""""_ _
<br /> 3_ _ -
<br /> Distance to nearest: We11_-._ . --. ___ Foundation___ # y c � a {
<br /> ,. fJ y s - - Propert me__'
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<br /> SEEPAGE PIT ,y[ ] De th_.�O _: D-iameter -- --- ---------------
<br /> �� t = ` R Filled N
<br /> p k N'umb'er e
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<br /> Water Table Depth- °____-- _ x
<br /> • Rock Yes
<br /> __ --------Rock Size-- = --------------------------------
<br /> Distance
<br /> = `
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<br /> Distance to nearest:Well.__ < --_:-------------_._-------.Fou dation=-_`::--- Pr p L -"------
<br /> :. -r� . a -__ - me
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<br /> REPAIR/ADDITION (Prey. SanitationPErmit#_ �°"_---:tee- .=----- --------:Date-------- ~-=.•- _--=-.- :--1 -:--------) 6
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<br /> F _____:__._ ---------____.____-___r_ _Y ,
<br /> Septic Tgnk (Specify Requirements)--- _. ___-_-
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<br /> r ,
<br /> Disposal Field (Specify'Requirements]-,__,,_,:_,,_,_.____.-_ "
<br /> s -------------- --- - --------------------------------------- ------------------ ----------------- ---------------------
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<br /> _ =
<br /> {Draw g existin and'req uired 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 San Joaquin Local Health District, Home owner or licensed agents
<br /> signature certifies the following:
<br /> AV*
<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 Workman's Compensation laws of California.:'
<br /> Signed - , ------------/f? _�_;Owner . .
<br /> �By-1 - j 01e,v-vs- --
<br /> ---------------------------- Title--- Gtr_._ /!:_ ✓fir --,
<br /> (If other than owned
<br /> FO DEPARTMENT USE ONLY
<br /> APPLICATION ACCEPTED BY - -- --------------
<br /> ----------------------------------.-------- -DATE.-- /, f
<br /> DIVISION OF LAND NUMBS :____
<br /> = - DATE-..:. `
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<br /> ADDITIONAL COMMENTS---------------------------------=-- = k_, ------------
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<br /> -----_..---- ._4 ------ - ----
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<br /> ------------------- --------..---.------ --------- � -----------•-'�--- � # " �- _ - -- ._r----
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<br /> Final Inspection•by; �---- ;
<br /> -- - ------ - - ------- - -------------------- -------------------- ------ =---Date.f�---fi�- - 7--'--`-'=------------
<br /> EH 13 24 1S f
<br /> �AN J AQUIN LOCAL HEALTH DISTRICT F&s 21677'-REV, 7176 am
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