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FOR OFFICE USE: FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT ��f / <br /> (Complete in Triplicate) Permit No._--- _--_""._ <br /> 06 <br /> ------------------------------------------------------- <br /> - <br /> �- _ <br /> ------------------------------- - -------------- ----- This Permit Expires 1 Year From Date Issued Date IssuedT-#-- <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 Ord" ante No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA ON__ .tG_ -J ----- _ --- ------------------------- - -- ---- -. ----`'._CENSUS TRACT------- --- -------- <br /> Owner's Name ------ - ---- ----- - --- _ -------- - ------ ------ <br /> Ad <br /> --- Phan <br /> } - --- <br /> yy <br /> Address = - r --rv-----------:�- -- - - -------- - -'( - <br /> t f— _ <br /> ,, +k .. ,. , � Y- . -- �_-- - -.-----� - ----------- -zip------- ------------- - <br /> Contractor's Name = _ �o Ci ! <br /> - License #---32��'_'._Z_"-Phone <br /> } <br /> Installation will serve: i Residence Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> *. a._...., Motel ❑ ; Other <br /> --------- ---- �.,t. <br /> I { I <br /> Nurnber,of living units: -"__- Number.of bedrooms_._L� "Garbage Grinder.--, '.,Lot,Size= <br /> -- <br /> Water Supply: Public System and-name----.-=---- ----- = ---------------------- <br /> ------------------------Private ®� <br /> Character of soil to a depth of 3 feet: Sand 'Silt :Cla Peat Sandy Loam /-C,-ay Loam ❑ <br /> Hardpan ❑ ' Adobe }] i .., <br /> Fill Material_-..-- ------ yes, type-----------------``-- ------" <br /> (Plot plan, showing size of lot, location of system in relation to-w.ells,:-bu.i.ldings,:etc,'must be placed on reverse side.) <br /> a,. 1_,, t__ - <br /> NEW INSTALLATION:' IN septic tank 'oF se' ge pif'permitted if public sewer-isa-available wrthiri 200 feet,[ <br /> PACKAGE-TREATMENT ['] SEPTIC TANK [' Siie ` /X-f .X _�3 -- � 1 <br /> k [ _ --� '- rqu id Depth <br /> F. <br /> t. . . . f, Capacity d'p='TYpe ' Mater' Na-Compaq#nts------+_: -------------- i <br /> .:Distance to�earest: Well----- ---0---f__---`�t.. " " __--Foundation 0 y { <br /> oundatio -------/ ------------ Prop. Line- <br /> LEACHING LINE [t] No. of Lines---- ' .Length of each Lina__._; <br /> .Total Length----- <br /> ------------------ <br /> I <br /> = - <br /> k f <br /> D Box----/_-_.`_Type F,iiter Material_--------- -f----bepth Filter Material-- -------- - --- -------- ------------------- 1 <br /> Distance to nearest: Well_'___"_�-_C?Q--- _-l oundati ii":} pr .[ <br /> i <br /> Line----------------- <br /> I <br /> [ ] Depth_ "_. _.: #er- --K--- -----Number------------------�— <br /> operty "" <br /> - � - --- -----.-- _ � Rock Filled Yes � No EJ <br /> r 11 <br /> Water;Table:Depth ! -Q Rock Size 1- ---- ---------------------------------1 , f <br /> REPAIR/AD Distance-to.nearest:Well___.--- ---l_--V�- -------------------Foundation_-,__�__Q---_ Prop, Line._ <br /> r ---------- <br /> DITION-[Prey, Sariitgtion Permit#------------------------�. <br /> 1 <br /> -- -- - <br /> 11 <br /> Septic Tank (Specify Requirements)--,-.-'`----------- ----- ---" <br /> ------------- <br /> -- --------------------------------- -------------------------------- <br /> Disposal Field (Specify-Requirementsl .-.-----:---_�"""- <br /> ----- --------------------------------------- <br /> --------------------------------- <br /> ----------I-------------- -- <br /> ---- ----- - ------------- --- - <br /> ---------------_ E ------ ----------- ------- ------------ - ----- --------------------- ------------(Draw-eisting +w J <br /> and required addition an reverse side] . . . 3 j <br /> I hereby certify that.1 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 /> "I certify that in the performance"of the=work for which this permit•is,issued,_-1 shall not employ any person in such manner as <br /> gt - <br /> to eeom.e.sub'ect to Workmanss Com ensation .laws .of California.". O` <br /> i <br /> Sighed .�° <br /> -------- ----- ------------- <br /> BYpt --------- ---------f - <br /> e-0 <br /> -" Title <br /> S <br /> (if other than owner) <br /> ' FOR"DEPARTMENT USE ONLY' I. <br /> i <br /> APPLICATION ACCEPTED BY":_� f ---------------------------------------------------------DATE ._7-1 r � <br /> DIVISION OF LAND NUMBER,____..:""_.__:_."""-__ / <br /> = ------------ <br /> ._ DATE <br /> ------------- <br /> ADDITIONAL COMMENTS - <br /> } <br /> -------- ------------------- <br /> ------------------------------- <br /> T ."___ <br /> -----------------------------------------_"- ______._-"-""._____.__"------ ___.. <br /> ""---------------------------------------� --- - -------------------------------------------- <br /> __"_"_--_____"""-_______ _--'------ <br /> -•------- ---------_____."""____ <br /> _' f <br /> - - ------------/-�------ <br /> -Final-inspection b ------•------Date-------- --- <br /> E" '3 - <br /> 24 SAN JOAQUI LOCAL HEALTH DISTRICT F&s 2r6�-,-.v- <br /> . ;,,6 aM <br />