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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 03 <br /> --------------------- ------------ Permit No---7� -- <br /> -- ""- (Complete in Triplicate) -------- <br /> ---------------------- <br /> "-- ----------------------- ----------------------------- S76' 7 7 <br /> Date Issued_________----------- <br /> ------------- ----------------------------- <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: T { <br /> JOB ADDRESS/tOCAT10N.- -------".�--------- -- ----------- --- ------- ------------------ --------------.CENSUS TRACT - .. <br /> Owner's Name.- ------ -----/ ---- --- ------ - -------- ----- hone- ------------------------------------- <br /> . <br /> ---- ------------------ <br /> k __- - r y <br /> Address--- -- ----- --- ( r City - ZiP - <br /> Contractor's Name___-- --------------=-------License ._--Phone_-- <br /> �- ala <br /> f -e: Residence,# -,Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Installation w311=sere Motel ❑ -Other---,'----------------------------------------- t <br /> Number of living units:._`_- "_____Number of bedrooms_L.7�------Garbage Grinder------------Lot Size-1 �Xe" 7------------------- <br /> Water Supply: Public System and name----' ' . : .. --Private <br /> - t <br /> -------------------------- -- <br /> Character of soil to a depth of 3 feet: 1 Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan E1 : Adobe ❑ Fill Material.............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 /> .(N <br /> o_s60tic tank •or seepage pit. permitted if public sewer is available within 200 feet,) <br /> N6V INSTALLATION: <br /> PACKAGE TREATMENT [ '] SEPTIC TANK ["] " : Size--- _.1_d------------_------------Liquid Depth_____._______.__ <br /> ' Ca cc jj ` ""`-.. <br /> Otp-2T` e.- Mdseriat- No. Compartments-= <br /> P Y YP +d....... G = <br /> r Distance to nearest: Well--------- _ ------- Foundation-1. ---_______________Prop. Line' __ 0_-_"-_ <br /> LEACHING LINE [ .] Na, of Lines_.__ -._ __.__.:_____.Length of each finsr' __�___ _____________Total Length -__ _ .___.____-___.____---_-- <br /> i� 3 <br /> 'D' Box--,�____-_Type Filter Material______________"'.Depth Filter Material______-_ _ __-_ <br /> r .y i -------Foundation_ �--- ------ --- . <br /> Distance to nearest: Wel!____�_��_._.__ _ � _____.Property Line______ __ _ . _______..______. <br /> [ ] De -------- <br /> p --___-___-_.-_ meter�,�.�_�_�.Number__-__�, � Rock Filled Yes No <br /> t Table Depth--- ------=------ ------------ # Rock Size _ <br /> -- - ----------------- <br /> 'Water --- <br /> i Distance to nearest: WeIL _1~ ------ •--- foundation__-----------------------Prop. Line____,7?-_ ---------- <br /> i REPAIR/ADDITION (Prey:Sanitation Permit#--------------- -------------------'_- ----#---.Date- "---- _-----------------------'-------_:---} <br /> Septic Tank (Specify Requirements) ...... ° -----=-- -----------------w---------------- ------------------- ------------- ------------------- <br /> Disposal <br /> -- ------------Disposal Field (Specify Requirements)---- -: ,.---:-------- ----- -----------=---=- j--------------------------------------- --- --------- -------- <br /> . -----= --------------------- ------------------ ----------------=------ --------------------- ------ <br /> 1 - <br /> (Draw existing and required.addition on reverse side) <br /> 1 hereby certify that 1 have;prepared 'this ,application and that they work wily be done in accordance with San- Joaquin County <br /> Ordinances,, State Laws, and Rules and Reg Ilations._of_-the.•San-Joaquin4Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> r <br /> "I certify that in the performance of'the}work for which"this permit is issued, :I shall Inot employ any person in such manner as <br /> to become subject to- Workman's. Compensation laws .of. California.'.' t <br /> Signed_ f ` <br /> .".OTwitltene <br /> er� <br /> .W.�_ <br /> =BY------ -------- �(!f of e�than ovine <br /> FOR'DEPARTMENT USE ONLY 4 <br /> APPLICATION ACCEPTED BY - ------------------- - ----'-----_---- --------- DATE.a1 � - <br /> DIVISIONOF LAND NUMBER ---- ---=------------------ -------- ------------------=-----.-•--------------------- DATE �------------------------------------------`--- <br /> ADDITIONALCOMMENTS -------------------- ---------- ---------------- ---------------------------- -------- - - -------- -------------------- ------- --------------- <br /> � k <br /> - <br /> Finaf Inspe ion by:: } L d-- --- --- . <br /> EH 13 24 SAN JOAQUIN LOCAL FfE LTH I !C' 7 RE . 7F763M <br />