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,FOR OFFICE USE; FOR OFFICE USE: <br /> _• APPLICATION FOR SANITATION PERMIT <br /> r' <br /> --------------------- <br /> (Complete in Triplicate) Permit <br /> Date <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 /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ,ry <br /> JOB' ADDRESS/LOCATION.__ - 0 r CENSUS TRACT ' _ <br /> Owner's Name__ t , 1i!1_. _ _ _ i ----- P-17O . <br /> - Phone.- <br /> 5:2-I>ho �3-IV <br /> P-1710 <br /> -------------' ' City tY -------- <br /> --------------Zi ------------------- -------- <br /> Contractor's Name.' --- -� = r---r—si "` p�----��// .� one d <br /> License # L_5 - ----Ph '�� <br /> �� � S D, s <br /> Installation.will serve: Apartment_ Mouse. Commercial`s Trailer Court; ❑ , <br /> Number of living units:_, Number of bedrooms k___________Garba a Grinder- ,.-_- .Lot.Size------------+ _ <br /> Motel ❑ Other = <br /> { <br /> �L . r <br /> i Water Supply: Public,5ytstem and'name " �.: --------- Private ❑ <br /> _ _ _ <br /> .� _ mom. .�_ <br /> Character of soil toa depth of 3 feet: Sand ❑� Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> 4`Ha dean❑ Adobe ❑ Fill Material-----------If yes'ty:pe ` ____ ___________.__ _ <br /> ---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings'etc. .must be placed on reverse side.) ,J <br /> NEW INSTALLATION- No sepfic3tank`or.see ' ge pit permittedifpublic sewer'is available within 200 feet,) p <br /> PACKAGE TREATMENT ( ] !- SEPTIC TANK Size - ------------------- --Liquid Depth---------------------- <br /> "". -Ca acit - = --TYPe-------------- Mateial-'- --- � -No. Compartments----16�---------------------------- <br /> Distance'to nearest: Well-__.j- _ __________________________ Foundation_:__ d___ <br /> 1 + . -------Prop. Line �S <br /> LEACHING LINE ` °[ ] Na_ of Lines._- _ _----------_.----Length`of each li.ns.___.___fd. ____._.___Total Length._ � . .,: <br /> r <br /> D' Box--w.__.Type Filter Material_`&-----Q Depth Fi]ter Material _.____. <br /> r Distance to nearest:Well_ l______________________Foundation-_.._ _. ___________.__.Property Line___.___.____._____________-_______. <br /> f = - <br /> SEEPAGE P1T ]' Depth._ Diameter)QA.�_.____-Num ber--------- ________________ Rock Filled YesXj No <br /> Water Table.Depth----------------------------------------------------- - Rock Sizej. <br /> ----------------------- <br /> 3 Distance.to nearest: Well- M' -----------------------------Foundation---,?#--.-------------Pr' <br /> op, Line---------------------------- <br /> REPAIR/ADDITION <br /> --- -----------_-__-.REPAIR/ADDITION (Prey..Sanitation-Permit#--------- --- -------------------L--------------.Date.----- ------- -------------------------------) <br /> Septic Tank [Specify Requirements),--�-" - <br /> = ----- -------- - <br /> -------- ----' ----------- <br /> i€ 9- ��- - <br /> Disposal Field (Specify Requirements)=,- -- ------------------ ------------------------- ------------------------------------------ ------- -- -------------- --------------- <br /> ---------- --------------- --------- " ;rte-. .r. _ <br /> ---------------------------- - ------------------------------- <br /> ...•rte+-.. r w . _.-. - t-,_`re—,--- �¢ ? <br /> [Draw existing and required addition on reverse side♦9« . <br /> 4 I hereby certify that'l 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 /> 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 ws o California." <br /> a I <br /> .le�tto Workman's Compensation <br /> Signed--/.1-i `- .,r'�- '",�`- . �,--- --------'---- - -Owner <br /> BY = ;`' {r = = Title <br /> (If other than ao vner)' <br /> rl (ir7£. > ,FOR DEPA ENT USE ONLY <br /> f <br /> APPLICATION ACCEPTED BY_. -----------DATE--- ----_`S ___ <br /> DIVISION OF LAND NUMBER '-!��" " - --_---DATE-------- ----------- ; <br /> ------------------------- ------------------------------- <br /> ------------------ <br /> -ADDITIONAL COMMENTS:-___t_ <br /> --------- <br /> w. --ra <br /> i <br /> y___________________________________________________ _____ __„________________ _.___________._____________.____________-________________-_--___- _------_ ______________ _____ <br /> Final Inspection by:-':w''-_ -- __. __. _ _ " ------- ------------ --Date 1 <br /> E;13 24 SAN J AQUIN LOCAL HEALTH"DISTRICT F&5 21677 REV�-71LJ6.3M <br />