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-FOR OFFICE USE: j�r' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� <br /> - <br /> ------------------------------------------------- <br /> (Complete in Triplicate) Permit No.,179J ___."__ <br /> ------------------------------------•- <br /> [ <br /> ---------------------_-----_--------_-----_-------------- This Permit Expires 1 Year From Date Issued Date Issued,<Q_-3G'.-26' <br /> ' Application is hereby made to the San Joaquin Local,Health District for a pe �tar5_1_n_stllrmitto constrthe work herein described. <br /> This application is made in compliance with Coun't-x Ordinance No, 549 and existing Rules and Regulations: i <br /> JOB ADDRESS/LOCATIO .__ .. <br /> �-- � - � - --------------- --Q ---------- -- - ------.CENSUS,TRACT.------- <br /> Owner's Name------- ---j- -- <br /> Address.. <br /> D .. <br /> �-• J---_------ - �rCT <br /> a Address-----=------------ ---- - �-- � i _ Cit ] <br /> -� - -=- ---- -------- ------------- -----�----- --- -- ---•-----Zip -----_---- -- ---- <br /> Contractor's Name__- - --------- ?-d �------dv�- "r----- - --------------License # .- .� �. Phone---- <br /> -------- "----I_f--. <br /> Installation wil! serve: Residence partment House.❑ Commercial ❑ Trailer Court ❑ <br /> � � � t <br /> ( t. 4..Motel ❑ -Other---?-------------- ------------------------- - . . <br /> Number.of living units: 2—Garbage <br /> / Q IJ <br /> -:- :l �. jg er_ _ Lot-Size (� _�,!_�-------------•--� --� <br /> Water Supply: Public System andNplmbeer-of,be oo �:_-__ _- Garb� G ind �.__. i ` <br /> �I (�'�- _ • } ---------- ; ivate ❑ <br /> Pr <br /> Character of soil to a depth of 3 feet; Sand ❑ :Clay ❑ I Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> ,Hardpan ❑ Adobe yes, type--------- <br /> p <br /> Material---____._.__If e <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 1.NEW INSTALLATION: (No septic tankYorRseepage pit permitted if public sewer is available—within 200 feet,] <br /> PACKAGE TREATMENT ( ] .,"SEPTIC TANK (1] Size---------------------------------------------------- ----Liquid Depth___ __._-------------_t._ <br /> f . r <br /> Capacity-------------- Type---------- -------------Material ------------------------No. Compartments--------- I-------------------� <br /> :. . lDistance to nearest Well--------- ---- ------`Foundation - ----------- Line- - <br /> -.- " ----_a._S, <br /> p I <br /> LEACHING LINE t g __Total! li:' Jl '_ _ <br /> .. . Irl iNo.,of.Lines------------ - -- -• Length of each line.--=_-__-� -_- _ r -- -- -- ------ <br /> I ! <br /> 4 <br /> I D' Box . = Type Filter Material:____. ,__ -_Depth Filter Material___ _ ______________ i !_ -_ ) ��-_._ <br /> � 4. .to r; .. 1 Foundation-----------------------------Pro Property Line' <br /> p. istance to nearest: Well-.-- p ty ' <br /> SEEPAGE PIT I ] Depth _._._ Diameter . Number --------------- <br /> f <br /> i Rock Fillad ' Yes ❑ No ❑ <br /> Water Ta61" Dep- -- ---. R Sok,Sizer ! -i--- <br /> - <br /> Distance:to nearest: Well.-------- ---------------------------Founddts {' --- _ -- c <br /> F : —1 -- - <br /> y 3 -----.Date -•------------------ <br /> --------------- <br /> Septic <br /> ------- -- ] <br /> REPAIR/ADDITION (Prev.ii,Sanitation Permit# _- --_ -- - <br /> Septic Tank (Specify Requirements)--- ------ '------------ ----------------------- <br /> ' <br /> Dispos Field,(Specify Requiramentsl--------------------- � -__ ---- fir x-F ---- <br /> fn -- - <br /> z v � <br /> - " 'r"r :::...--/`---1 - -x. -- ------ ----- f.- <br /> ---------------- <br /> 7 <br /> ------------- <br /> t ------------ <br /> --------- ---------- --------------- ------------------------------------------------------------ - ' <br />` ! (Draw existing and required addition°on reverse side) [ { <br /> a � <br /> I hereby certify that,l have prepared,this application and that the work will• be done in accordance with San Joaquin. County <br /> Ordinances,7 State Laws,. and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> r signature certifies the following: - <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 Ca ..lifornia." <br /> � s r <br /> Signed = -----=----- ------------------------------------ - -------Owner <br /> - Title BY E � - ------------- <br /> (If other than owner) <br /> FOR DEPARTMENT_USE_ONLY' i <br /> APPLICATION ACCEPTED. BY- = ------------------------------------------------------------ DATE --- ®.'_.�©------ --------------- <br /> DIVISION OF LAND NUMBER-------- ----------------- --- ------ z e 0, ` DATE------------------------------------------------- <br /> ADDITIONAL COMMENTS------------ -- --------------------------- - - <br /> ' ------------------ -------------- == ' $` X07, ------------------ <br /> i ----- ._ ------ - --------------------------------------- -- -------------- <br /> -- ----------------------------------- --- <br /> Final Inspection by:_;-__. _ - = - - �.'. == == ---Date -- �1 <br /> EH 13 24 R SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br /> u <br />