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_ FOR OFFICE USE. <br /> .� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> _ Permit <br /> ` -------- -------- ---------- --------- ---------- - (Complete in Triplicat;') <br /> ---- --- ---- --- -------- ---- Date Issued.ill, ?� <br /> _- This Permit Expires 1 Year From Date Issued <br /> L Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> pliance with County Ordinance No. 549 and existing Rules and Regulations= <br /> This application is made in com <br /> + �} a <br /> JOB ADDRESS/LOCATION-..------ -3 ---- <br /> .: . _<- , --- -� - CENSUS TRACT.. - M <br />' wner's Name. i _ - �Jf.+l 0e --------------------------------------------- . ----------------------- <br /> 0Y €� ---zip - ----------- <br /> ----------- <br /> Address <br /> - ----- <br /> Phone -- <br /> i Address--- r.. : /"� -- --- �CL R <br /> } ► } <br /> Contractor's Name °� �- _ _- - License #�,?�" - ; -Ph ne- c <br /> J 0 <br /> Apartment <br /> [r]a. rt,ment House & Com <br /> me E] Trailer CoutL[-IInstallation will erve: sidence Other.___.€O__ " --- --„te <br /> t <br /> r <br /> Garbcfge Grinder_. Lot Size_.,.-------- <br /> Number of livin units: Number_of1bdroms-_ # <br /> Private <br /> Water Suppl): Public System Wand'name_ :_e..:= :;..:---'------ 7�.----: ----:--=------------------------------ to <br /> Character of soil to a depth of 3 feet: ; Sand r] :Silt El -Clay El , Peat F] Sandy Loam Clay Loam El <br /> p _. <br /> I Hard an❑ : Adobe ❑ ; Fill Materal __.____.._If yes, type__._,___- -____ ' <br /> } <br /> (Plot plan, sh#wing size of lot, location of system in relation toelll}s,,builddings 'etc,must be placed on reverse side.) <br /> NEW INSTAL>CAT10N: {No septic tarik,or seepage kp�t .permed if publsic sewer �s available within 200 feet,) F <br /> + t ----Liquid Depth-------------------------- <br /> PACKAGE TREATMENT II . SEPTIC TANK A;Zn [ TY e -p�eSize� �- -- --- -4 E ; <br /> : Material-----------------------=-NCompartments-__-_-� <br /> ------------ <br /> o. <br /> s t. .. ., Capacity * r ,Yp, c <br /> L - Foundation:-AI------=-- ------Prop. Line___` <br /> ---- <br /> ] Distance to nearest. We1!__: _ - '- � ....... �� , <br /> 9 --- <br /> f <br /> Len th of each line--jr�'_ '-- -Total Length :_,- ---__""-- ----------- - -'� <br /> LEACHING LINE [ } Na..o# Lines :_ :-.-- ,'----:- ::. 9 N <br /> Q' Box._: --------T a Filter Material✓/ Depth Filter Material-_` ------------- <br /> - <br /> i i I yp . . ._ s - <br /> Property Line---- --��-- <br /> r Distance to nearest: We1!_-__'��------------------'-Foundation___' ' '--- --.-----_ p Y <br /> s' Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth.- `-----------Diameter Number = = 0 ❑ <br /> Waterable�Depth.-- - ----Ro ..S - <br /> ck'i i e <br /> I ---- ----- .. r <br /> Distanceaoi`e est: Well - = '`'Founda n ---------------Prop. Line -{ <br /> : } }'`'." <br /> REPAIR/ADDITION (Prey. Sanitation Perm` - --- ---------=------- -- -Date__-___-_ ___--_-__-- ] <br /> ------- 9 €: . -- -- ---- <br /> ---------- - = ---------- <br /> Se <br /> -----. , <br /> Seic Tank (Specify Requirements)_-_______-.---:-:--::=-----------�- --,-----• � f <br /> - " -- ---- -- ------ ------- ------------ <br /> pit <br /> ---- ------------ <br /> Disposal Field (Specify Requirements)_---------- ----- - --- .' - -------------------------------- <br /> ----------------- <br /> ----- - ---- --------- <br /> 1 ---------- --------- --------- ------- ---- ------- <br /> ------------------------------------------ <br /> i - _________________________________________ _________________________ '� ______ <br /> } <br /> l <br /> t -- ----------< averse side] , <br /> i g " <br /> ( ,---moi raw e) stip and required addition ort r <br /> s ej, i }_. <br /> { work will ,be done in -accordance with San Joc€quinCounty <br /> I hereby certify that 1 have pF epared This application ation and that the wo s � u 4 . <br /> Ordinances,' State Laws, and Rules land Regulat'ons cof-the:San Joaquin' Loial He#alth District. Home own r orklicom agents <br /> I' signature certifies the following: y ! ! 1 <br /> i I' . <br /> "I certify thatin the perforrrt6nce of�fhe word"of"r which fhis pe mitis issued, I shall not employ any person m«suc► manner as <br /> to become sub'ect t o;! a�nompensation. laws_of. Calif gif 4 A - <br /> Signed <br /> L _ _... :. er .-..... .� <br /> I <br /> -t <br /> - - ____ _ r <br /> (If other-than owner) 'DEP TMEN <br /> . i <br /> �. 1 <br /> pOR T`tJSE NLY' <br /> APPLICA.T.I.ONAC-CEP�ED�BY- --- -. - - - GATE' l_. _ _ - <br /> --------------- <br /> 1tf, ATE <br /> ADDITIONAL COMMENTS...-- ---- --- ---- --------------- ----- - �' y` '` <br /> t DIVISION OF LAND NUMBER-..-.__:--_ - <br /> = ------------------- <br /> [r ------- <br /> --------------------------------------- <br /> --------____ ___ ______________________________ .. <br /> __________ ________ _ _ _ __ __- <br /> ( ------------- ---- ----- - ------- ----------------- Q Z � ---------=------- <br /> --------- ate <br /> Final Inspection,by:-- ------------------------------------- <br /> ' F&5 27677 REV. 7/76 3M <br /> EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT <br />