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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICAON FOR SANITATION PERMIT <br /> ... X33 <br /> ------------- ---------- ----------------- -------- (Complete in Triplicate) Permit No-- - -'---------- <br /> ----------------- ------------ Date .Issued__ ___________ <br /> ' 7 a_ . <br /> z , <br /> _"- <br /> --------------- This PermitExpires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct-a6d install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J (��� ' <br /> _CENSUS-TRACT-.-- -------------- <br /> JOB ADDRESS/LOCATION- ` T -.'-"±� --`'`"" <br /> Owner's Name--------------- ---- PhoneS', =_ ? <br /> t --- . fir/ <br /> Address- - 7 — �� Tb(� <br /> _ 6ity - ------ -------- ZiP <br /> ------- - _ ..^T <br /> r ,._ <br /> Contractor's Name--'. = - { ._License #_ _3.T Phone <br /> Installation will serve: Residence Apartment Nouse.❑` Commercial= ] Trailer Court ❑ <br /> =r--....;...r.;._.. . -1 Motel ❑ Other------ -----------'-- ------- - ------- ----- f <br /> t i f !./. ce <br /> Number of living units:__'._ _ +ge Grindea'__--.__.. -!Lot Size.,___L--_------�--�- <br /> I _ Number of bedrooms.--. -- Garbo .� ---------- - ------------ --------private <br /> _Water Supply: Public System and name.__ .____ - -----"- ._.------------- <br /> -Pe-551`0 <br /> - <br /> it ., j_:,. � <br /> Character of soil to a depth of 3 feet:; Sand ❑ Silt �C1.ay=❑ Pe'aT•❑ 5an yttoam ❑ Clay Loam " <br /> I Hard ori Adobe Fill Material__._.__-_.__If yes, type-----4_________________ ______ <br /> i p ❑ ' ' <br /> (Piot plan, showing size of lot, location of system in relationjto wells, buildings, etc. must be placed on reverse side.) <br /> 4 +ww <br /> NEW INSTALLATION: -,(No; <br /> septic tank or seepage pit permitted if public sewer is€available within 200 feet,]NEW <br /> ! {{ E <br /> PACKAGE TREATMENT [ ] SEPT IC TANK [I Size------------'w=."------------ Liquid Depth ;---------"----- <br /> ' Capacity _.. -`TYPe ==` = Material------------------- ----=-No: Compartments------------------------- --------- <br /> ,� ! _CI <br /> 1 Distance.to neares.6-Wel4l.- . --------- :Foundation....R = Prop. Line. .J <br /> l � .r <br /> LEACHING LINE: [ ] Na. of Lines-:"-----;.,- .-----=:--:-:Length.of.each line._--:------ :: ._:�o±al" Length "----------------------------------- <br /> I D Box .__. Type Filter Material __.Depth Filter Material_. ---------------------------- <br /> SJ . . #. . ,f r . _ <br /> ,...._.t <br /> i �' l],istanca to nearest: Well----------------------- _.Foundation _ Line_ <br /> _ <br /> t �Propert R Line ----------------------- -- --IV <br /> Filled Y N <br /> '- -----Number__.: F <br /> SEEPAGE PIT [ ] Depth -. -- -------D;iameer�,�--: - ❑ <br /> "� t <br /> i Rock Fi s o <br /> �. - <br /> ------- <br /> Rocze- I <br /> p Stan sato] nearest: Well.w :w` = `� -:Foundation.-- �---'--- -' .Prop. Line--- :-.--------------------- <br /> REPAIR/ DITION (Prev. Sanitation Permit#__ Date i ..._._ ,r;] '` <br /> ( �r f .1- - <br /> k <br /> t �t Y <br /> ank (Specify.,Requirements]- _•- _ -- -_.- <br /> i <br /> Disposal Field.(Specify Req uirerrments)___._:_. ��----ll?o- - �-------- <br /> -.----- `----- ----- --------------- ------------------- <br /> ------------- <br /> t l ----- <br /> ------ ---- -----' ---- ---- <br /> # - -- ---- <br /> ------ <br /> _ = T <br /> t (� existing and required'additi non reverse side) F <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: r <br /> t <br /> "I certify that in'the performance df:'the work for which this permit is issued; I shall not employ any person in such manner as <br /> to become subjr=-tt to-WorlemanI Compensation-.laws,-of-Calif ornia.". <br /> Signed- --- - ----- -- ----- ------- <br /> -- - ------- _ _- <br /> --_--=- Owner <br /> �•. <br /> By-------- ' <br /> -r---Title------ <br /> (If other-than owner) <br /> --- R DEPARTMENT'USE ONLY <br /> APPLICATION ACCEPTED: BY ---- - -- `::.DATE ------ °P. ---- <br /> DIVISION OF LAND NUMBER------ _ -- <br /> DATE------------------ ' <br /> L COMMENTS - <br /> f _.._-_.-"________________________________ ________________________________________________ ____ __ S <br /> ADDITIONA ------------- -------=---- <br /> ------ - -------------------- ------------- -------------- <br /> ' ---------------------------------- -------- -------------=----------------------------------------------------------------------- <br /> eH i Ins ection.b -�--�--�-�-�" '.."""" - •. - ..,. :,..,. ------------- -------.-- - Date ----------- ------------------------------ <br /> Final ------ --------------------- <br /> a 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s tie» R �7li 3M <br />