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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - L <br /> (Complete in Teipq ate) Permit No.__7d__-'----___.__ <br /> ,e'; r{� ,� Date <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:-5 9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-__ �.___ � <br /> - © --<-•-----���(�„SdJI�..�C:l� --------=- - ----- ----------...CENSUS TRACT-- <br /> Owner's <br /> ------------- <br /> 1 ��1--------------------- -- _' rhone-.36q <br /> / (� �- <br /> Owner's Name_,. - ----------:'--------- -- - -------Phane-. �1�" s'----------- <br /> -------------------- <br /> � <br /> Address-._.___._ <br /> --------- ------ --------------------------------- I _. <br /> �A"ra1-�----�------------- --- - � � -'City-- � -- - -------------- ZIP Yn--`���-�-------- <br /> Address <br /> --- - <br /> Contractor's Name--- _..�� --------------------- ---------License #-[cv- -7 � Phone_- <br /> --------lam _ <br /> Installation will;serve: Residence � Apartment House.❑ Commercial ❑ Trailer Court ❑ <br /> g ' --------- ------- I =----------- � <br /> Number of livin units--------- ----Number of bedrooms- y i <br /> + - Mote ❑ Other <br /> ' Garbage Grinder _._.._Lot Size------`. �.,------ --��--.r��3_r_ <br /> I 1 <br /> I <br /> W ter Supply: Public System and name ------- •--=�--- --------- .------- - ------------------ ----�-----------------_-------- -Priv ' <br /> r <br /> Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt 0 Clay Peat❑ Sandy Loam ❑ Clay Loam Q = <br /> Hardpan ❑ Adobe ❑ Fill Material------------- yes, type------- -------------- l <br /> (Plot plan, showing size of lot, location of system in relation to wells, buil=dings, 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,] <br /> [ ] SEPTIC TANK [ ] .._T. r''Siz�e....--------------------------------... ., �_'".t"�"�. ""Liquid-Depth :_----: l <br /> PACKAGE TREATMENT ` <br /> Capacity f Type �- : -___No. Compartments-------- <br /> -------------------- -----------, Matenal___'.----.r- - - ---�n. Prop. Line -- <br /> Dtana to neaest: W -----Foundatio <br /> LEACHING LINES [ ] Na. of Lines=----------------- _ .Length of each line------- -----------=�-- Total Length-----------------__,_1_-------:------_--- <br /> i D' Box- - --._,Type Filt6r Material- ---- ---____,;_De;pth Fi,lter Material-------------------------------- ----------------- ---. <br /> Distance to nearest: Well.-- t...--_ -Founda{tion-------------- Property Line-------------------------------'.--. <br /> SEEPAGE PIT [ ] Depth._ --- --- ---Diamefe __-Number-----t - -_----- - ---------------- 14 Rock Filled Yes ❑ No ❑ <br /> 1 .. <br /> Wa"terjable Depth.""-I __ - _:--------------�Rck Size _. <br /> Disfance.to nearest: Well,-------------- ------ - ,Foundation------------------ --�Pcop. 'Line---------------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-'-_.-__ ------ <br /> --.Date__------------.- <br /> t --- - - ,r rmom'""_-----:_--____ <br /> Septic Tank (Specify Requirements)------------ ".__� <br /> ? <br /> ------ <br /> ----- <br /> Disposal Field (Specify R�e�uire--men�ts - <br /> i . - _ -y I( !��.� --- <br /> ' r-"c` �yu--k ---- <br /> /C <br /> -_ � <br /> ---------------------- ------ <br /> � <br /> y f}j-- ---r--- a -CY---- _ <br /> .� existingaewied side] <br /> I hereby certify that I have prepared this application and that the world will Abedone in accordance with San Joaquin County <br /> Ordinances,.State_Laws,_and..Rules,and Regulations of. the San Joaquin Local Health District: Home owner or licensed agents � <br /> signature certifies the following: ) { <br /> "1 cern that in the _ � '� <br /> certify performance of for which this permit is issued, 1 shall not employ any person in such manner as 1 <br /> to become subject -Work n's Compensation laws of California."I <br /> s <br /> i <br /> Signed------------ ---- --=---------- -- --- -------------- ----------------------------------Owner .. i <br /> Y- ------ -- --- _ Title. -. <br /> r If other than o ] <br /> FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED ' <br /> -- -------------------�--------------DATE.------- - - �:�C)'=--� --- <br /> DIVISION OF LAND NUMBER1------------------ 1 I --- DATE------------------------------------ <br /> ----------------------- <br /> ADDITIONAL COMMENTS/' ------------------------ ) --- <br /> ---------------------------------=--- ----------------------------- ---I------ <br /> ----------------------------- ------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- <br /> --------------------------------------- - --- ----- - --- <br /> --- -- ----- - <br /> Final Inspection by: f -. ,.� � ---- ------------ <br /> --------------- ------ � <br /> EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M i <br />