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ROFFICE USE: <br /> { <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: C <br /> I�' �(Complete in Triplicate} Permit ` 5d <br /> --------------------- a I <br /> I�. r r � r <br /> E. This'Permit Expires ] Year From Date Issued <br /> ------"- - ---.-- Date Issued- <br /> ThisApplication is hereby made J the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> application is made in compliance with County OrdinanN <br /> ce o. 49 and existing Rules and Regulations: <br /> JOB ADDRESS/COC TION " � � � <br /> Owner's Name.. = S <br /> CEN TRACT <br /> Address_." - -- <br /> f � � . . Phone" - - �y <br /> 1 - - - - '---- ---=-- <br /> Contractor' w <br /> s Name----- ---------- <br /> --- ----- <br /> .City- - f. Zip <br /> - = <br /> n . <br /> License Ph <br /> Instaifatio .will:serve: Residence "" . one- <br /> - <br /> s Mot Apartment House.❑ Commercial ❑ Trailer Court <br /> e ❑ <br /> '❑ Other- <br /> =-------- i <br /> Number of living units:__:.. <br /> ------------------------- <br /> Water; / -1I -Number of bedrooms_.._"Garbage i <br /> Grinder. Lot,Size_." f» <br /> Supply. Public System and name _ <br /> : " - - -- <br /> Chracter of soil to a depth of Ffeet: ` Sand ❑ Silt Cla . - P e ❑ <br /> Hardpan Adobe ❑ - y❑ - Peat❑ Sandy Loam ❑ Clay LoaLj <br /> m <br /> Fill Material".. If es <br /> ii Y type <br /> ; " <br /> - --- -- ----- <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings,,etc. must' i <br /> NEW INSTALLATIONe g be 'placed an reverse side.} <br /> {Nose�ptic tank or seepage :pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT t <br /> C '1 1 SEPTIC TANK [ Size-"," ?�.S9 <br /> r li - <br /> Capacity - ----- ------------Liquid Depth ------ ------ <br /> ------Type Y/Z� <br /> 1 I� Matert,af_�;1— _ <br /> -No. Compartments--'------,�- <br /> ------- <br /> J istance to nearest:.Well ` � �� <br /> LEACHING LINE "'1s b Foundation Prop. L,ne _5_t ` <br /> LEA <br /> [ } Na.,of Lines"_ - "- Length.of,each liria. r <br /> �r Total Length 1 � <br /> ;'D' Box.! ` -Type Filter Material" f � <br /> fe Depth Filter Material_, �_ :��" <br /> �ZClhd j�� :Distanc,to nearest: Well_ �--1_ _ 7 J '�f ---- <br /> ,., . . �-Foundation.---�Q <br /> Property Line c- .. <br /> �T Cy'' Depth._ "C�- ---- .Diameter". s � -- - <br /> ' = - ------- �---- <br /> Number-- -----�-- ----- ------ <br /> Water Table'Depth._":_ , R ed Ye <br /> E , ,-------------------------- <br /> . _� Rock Fill s.[ No <br /> Rock Size_--- ' - <br /> Distance:to nearest: Well- <br /> ---------------- � <br /> - <br /> iFoundation------ ` .Prop. Line S /f`P'- <br /> REPAIR/ADDITION (Prev, Sariitatikon-Permit#___--:----- <br /> i --------- ----------,Date------------------- <br /> Septic Tank (Specify Requirement's) ------------------- -" a s <br /> ------------=-----= --- <br /> _--. --- _-- " <br /> Disposal Field (Specify Requiremle�nts},--__-__---- <br /> [ - ---- <br /> i <br /> ---------------- <br /> - ----- --------------------------- - <br /> 1 1 (D!aw existing and\required addition on reverse side, #€ <br /> !.hereby certify that l have prepared this-application and that the work will be done in accordance wish San Joaquin County <br /> Ordinances,=State Laws, and Rules -and Regulations of'the-Sari Joaquin Local Health District. Homeowner or licensed a ents <br /> signature certifies the following: G, g <br /> "I certify;that in'the perforrriance�of the work for"which this pe'4nif is'issued, I shall not employ any-person'arson in <br /> to becoe 6Cect to W kma s Compensation'laws of California." p such mannerlas <br /> t '�.. i <br /> . <br /> Signed-17. �- i <br /> . - - _- <br /> y <br /> r .`—Owner r <br /> :Tile. - - ` <br /> t h: (!f otFer than owner) ---------------- <br /> FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED' BY~: <br /> DIV15lON OF LAND NUMBS. 1 �l. `` --------- "---- DATE <br /> „ --- - ---------------- ---- <br /> -- ---- <br /> - : DATE - --------- <br /> ------ <br /> - ---------------- <br /> ------- <br /> i t <br /> T. <br /> - - - ----� - --- - -�- - -= - - ------ -- ��-2�-_�19.�Slut m�r►1}�nc�--fol�� - � ... :--- ---„--------------- <br /> ADDITIONAL COMMENTS,-�,::,-._- <br /> IIir <br /> N-C.w � __ �T-" 1 _ ix Alf-J <br /> 9-4) <br /> 4 � ' O- <br /> - - <br /> -------- <br />--------------------- <br /> - <br />---------------------=--------------------- - r-- -----=- <br /> - - ----- <br /> -- ----------------------- �`------=---- ---- --------------- <br /> -Fiina-F-Inspection --- ------------------------ ----------------------------- --------------- - --�-- _ .-----------------------.rl 13 24 - ---Date------- - <br /> AN JOAQUIN LOCAL HEALTH DISTRICT y <br /> r' F&5 21677 REV. 7/76 3M <br />