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FOR OFFICE USE: FOR OFFICE USE. <br /> . . y <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No,_.�:.-'..."._7 <br /> `�:/.-'-�� <br /> ••-•••••.•• .•.......... ................... This Permit Expires 1 Year From Date Issued Date lssued_3. <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: <br /> JOB ADDRESS/LOCATI ....... .. ........--......CENSUS TRACT.............. } <br /> Owner's Name-------- Phone ........ .. <br /> Address 4:.-�-:...---?I. - _City. .. -- -----...Zip-- f <br /> ��,� 1',�..���� ,r <br /> Contractor's Name 1,�-���' i_ J"�"""�"' _ ense #,P7-C.4 <br /> 7.. Phone. <br /> Installation will serve: Residence Apartment House,❑ Commercial ❑ Trailer Court Elf <br /> Motel ❑ Other....._ ,-- -------------------------------------- <br /> q <br /> Number of living units:._ `,--....Number o€ edrooms._z2_....Gar'ba e Grinder._.` .Lot Size_//01 <br /> ".lF.. ._!............. .... <br /> op <br /> r <br /> Water Supply: Public System and name--- <br /> ----------_ :. Private <br /> ... <br /> Character ❑ <br /> of soil to a depth of 3 feet: Sand ❑ Silt E3Clay.[ Peat ❑ Sandy Loam E] Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material_ 4.. ....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 /> i <br /> NEW INSTALLATION: [No septic tarik"or seepage pit permitted ifublic sewer is available within--200.feet,) ) _ <br /> ., ._. _,. 1111 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 'Size.` , , .� t __ ___.. ....Liquid Depth."4.... _ . . <br /> _ _, <br /> Distance-�to•nearest. Well _ W�: r ' .Foundation '-__.,.........Prop, Line <br /> LEACHING LINE �( ' No. of Lines..__..."_ ._¢_.'_--- .Length of eac line.._/o49___.-____. Tota-Leng.�h:.f�0............... <br /> ..- S" <br /> D' Box..s". .__y'�T e Filter Material_. . Depth Filter Material--- -- yc �-- -------------Q <br /> Box-./ YP p � `•..._... _ <br /> ff a <br /> Distance,to nearest: Well. ` __ _.____ Faundation._.lf---I--i" f Property Line..__- .. ....� i .':...._ <br /> SEEPAGE PIT ' ;.= Depth.�4.r,�....Diameter... _ ......Number---- -- ----- ----:'__ Rock Filled; Yes ' Nol <br /> ., ! e F. .. <br /> ,fl ;r Water.. Tdble Depth------ a�_ - Rock Size <br /> y } <br /> Distance to_nearest: Well._._..-'--- .... Foundation.__.. ✓� _.......... Prop. Line... '.............:_... <br /> F REPAIR/ADDITION,(Pr`ev. Sanitation Permit#----------:'y_- -------- -- ----.....---Date....._.•--•------------------- ----•--.-----_) <br /> Septic Tank (Specify Requirements)----.............................. ----------------------- ------------------- <br /> - ----- ---------------- ------1---------------------------------- <br /> Disposal <br /> - - .....Disposal Field (Specify Requirements).......`...... = -• -------- - ------ .................. ----------- <br /> ............................................. ---- ---------- --------------------------------------------- ...... ---- ----- <br /> - <br /> --- # <br /> (Draw existing and required addition on reverse side) t <br /> I hereby certify that 1'have prepared this tapplication and that the work will be done in accordance with San{Joaquin County <br /> Ordinances, StateLaws, and Rules and Regulations of the San Joaquin Local Health Digtricct, Wo_mp_.owner or licensed agents <br /> signature certifies.the'following: <br /> "I certify that in the performance of the:work forwtiich�this permit is issued_ ,:! sh&II,Aot employ any person,in-.such­manner 3as <br /> to become subject to"Worktti-dn'T-Cbmpensation laws of California:' <br /> LARENCL'S <br /> rTIC <br /> ....._. .................._ ._..---------.. .-..._.__.._.Owner l .w e2G3 So.Oro`S P Sia �nFC�ai� SEii20 <br /> VICli ` <br /> ! By......-- = ffno <br /> .................Title .......Ph:�f�3.3��� <br /> Of other thr) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- ............ ............._ ----------- . ... ...DATE ...... ._ ... ...... ....: <br /> DIVISION OF LAND NUMBER--------------- ------ .....---------------...----.DATE.---- -. ....... <br /> ADDITIONALCOMMENTS------------------------------------------------------------------------- - ------------ - ------------ - .... -----.-------- ............ <br /> -..... <br /> Final InsQe6ion b -------------Date....__..----- 5.� .- ......_... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7/76 3M <br />