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FOR OFFICE USE: FOR OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- -- �4- <br /> (Complete in Triplicate) Permit No .........5...1... .... <br /> . _ y <br /> This Permit Expires 1 :Year From Date Issued Date Issued_.b/1V7. -. <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 /> JOB ADDRESS/LOCATI0, CENSUS TRACT...... <br /> N ...- --.--- - <br /> Owner's Name Phone..................•--------- <br /> Address..:.-._.. ' . . .. _. T- <br /> ---------- -- .. . .......... ... City ---- --- ------ -- ....... -------Zip..7. ... 5 ...}_ .. <br /> d2D <br /> Name. -��--,1L .� t /``�License #- -1.1 -7.--.-Phone ............. ... <br /> . Installation will serve: ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel Other.....- -- ----- - - --------- --------- tj�"'- �..��, <br /> Number of living units:......_.. Number of bedrooms..... Garbo e Grinder.... <br /> g gOt Size. <br /> Water Supply: Public System andname.... ...- -�G__ -------------------- ............:.........Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeAr 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,[ 4 <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ ) /l r�SiXe_. � - n --------------------------- ------Liquid.,Depth --------------- <br /> T. <br /> -- ---- -- :-- <br /> Capacity --- "�=:...Type. µ Material -----------------_- -No. Compartments: -' r$ <br /> Distance to nearest: Well- ------- . ' -'Foundation - - -;Prop. Line.•-.. ..................... <br /> LEACHING'LINE � No, of Lines .....:Y ._ ..:•-.. Length of each line .-`: _�-.------- Total Length . �.. <br /> .............. <br /> 'D' Box..��T.ype.Filter Mater[al, ...Depth Filter Material. /. ?.... r <br /> .�. . • � Distance to nearest.`Well.415lr.4�...F6undation,,.,-A ..._....ti..,.Property Line_. .............:..:�... <br /> SEEPAGVP1T : Depth- �:------------- <br /> Water <br /> - --.--_.-. Rock F':Ilecl Yes ' Na <br /> �. ....:.Diarrleter--- -: __--Number..-.--- .-: ❑ <br /> f <br /> ' .r - - Rock-Size.------ <br /> Water Table Depth:------���. .. : :...... .......:_- � --- -..._.. -•--------..._- <br /> Distance to nearesti,Well.___2' -..4�✓rC� .. _Foundation...........:........Prop. Line... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------ � ... _.........*.Date-------.....-.-=------- --- ------ <br /> --) <br /> .. <br /> Septic Tank (Specify Requirements)......_.. "' ` <br /> Disposal Field (Specify Requirements) .------ _., --- -- <br /> ----------------.. x .. • -- -- --- - <br /> .� / <br /> ,----- - ._........ ------ -------------------------------- ------ ---------------------- ------- ---------- � ---- <br /> (Draw existing and required addition on reverse sides <br /> - 11 I hereby"certify that I,have;prepared this application and that the wo kr will bee ddo 4—iin--ac-so-rEW-n a"with San Joaquin County <br /> [ Ordinances, State Laws, ya d Rules and Regulations of the San Joaquin Local Health,District. Home owner or licensed agents <br /> k 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 Woikman's'Co'm_fSensation laws of California." <br /> Signed-........ -- - - --.--=- Owner - <br /> . " • - LARENCE'S SEPT;C 8. SLVJ R SERVICE <br /> - --- ---�,.- - -... ,. <br /> 8 _:-.. .... 263 So. Oro 4 Sto kto , Calif. 95205y lrlic or=s; e: <br /> (If other .than ow ._ » .�... <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- .-.-....:---------------------------- --... .............. ......... ___.DATE <br /> DIVISION OF LAND NUMBER. _ - ---..... < DATE. <br /> ..---- ----- <br /> ADDITIONAL COMMENTS... - ` do .....:.... <br /> ............ ------- - --- ---- � a-.... ... - --.... <br /> �---------- - -- - <br /> Final Inspection b C.! - -- ---- -- --- -------- --- ----- ---- . -- <br /> --- ------.---..-...... <br /> � Y� ---- ------- --- - _ -•---------------------------------- <br /> ---- <br /> - Date- - -6. .-7�.. ._-,'"..-- ;-� ---- <br /> EH 13 24 - F&S 2!677 REV. 7/76 3M <br /> �� SAN JOA4UIN LOCAL HEALTH DISTRICT <br />