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FOR OFFICE USE; FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------- ---------------------------- - <br /> (Complete in Triplicate) Permit No._7f-/5 3 <br /> ----------------- <br /> ------------------------------------- ------------------- <br /> r <br /> _---------------------------------- This Permit Expires 1%Year From Date Issued Date Issued-- - <br /> Kpplication-is hereby am de o the'Sbrl-^Joa-u p Local Health District for a permit to construct and install the work herein described. <br /> This applicatioK icde-in--compliance with Coun y Ordinance No_ 549 and existing Rules and Regulations: <br /> JOB ADD{2ESS/LOCATION___.- '— � "�— <br /> "sa== CENSUS TRACT.------___--- <br /> Owner s Name-------- ` . -- -------- <br /> =--------- ----------- - - <br /> ------- -- - <br /> Address�..�_�__-� - . " - --- - 'ons•:-�.s�.� �_�:.;�� <br /> f`Cantrador's Name - - <br /> . _License #-,44 ,.��� <br /> .-:��M+.a.E �-• ' �-- -Phone - --Installation will will serve: Residence ❑ Apartment House ❑ Co mercial [ iler_$it�lF � <br /> Motel ❑ OTher------ ,�n <br /> Number of living units:------_!�' , _Nu_mber of be roofils- --/__-Garb Garbage,G�mder__-09^Lot Size--- 7_, _.14-- ,-f__ <br /> �' ---- <br /> Water Supply: Public System•and_name-____-- ---- Private <br /> - -- --- - ----- <br /> ------------------------------------------- <br /> e ' <br /> Character of soil to a depth of 3-Jeet: Sand Silt❑Clay ❑ Peat❑ Sanayy Loam ❑ Clay Loam ❑ <br /> ' <br /> F a'jpbn ❑ ,Adobe Fifl-`Mciterial- ----- -- if y S, type------------ <br /> I t r ' <br /> {Plot plan, showing size'of' location of system i? relation to wells,buildings, etc. must be placed on reverse side,) <br /> NEW INSTALLATION: {No septic <br /> } se�tic tai n:k. or seepage <br /> ee p e pit perm- - Medatferpiaulblic sewe"r"�is av�a- <br /> ilabe wit In UO eet,) <br /> PACKAGE TREATMENT SEPTICTAUK <br /> apacitSize- XLiquid Dept <br /> h---------------------------- <br /> No. <br /> -- ---------------------No. Compartments- . .Z <br /> y f y�� r <br /> ------- ------ <br /> Distance to nearest:WeILFoundation._ <br /> a F -.�., �� �- Prop. Line.-.,.5 <br /> LEACHING LINE [ ° tG5. W Lines-- ---- --------- Length of each oma - _---- --------------Total: <br /> ---- -Total'Length --- -------__________ , <br /> { 'D''�ox- _--_-Type Filter Material-�` _ 'De'Depth Filter Mate lr aY°-__"`.._ • �< <br /> p l --- --w-------------------------------------------- <br /> Distance to nearest: WeIL:� _ .______._-_Foundation___ G__ '______---_P perty Line__ y <br /> i----- -------------------------- <br /> SEEPAGE PIT Depthp` cS' .Diamete .- - ---Number _____________________ Rock Filled Yes No <br /> Water Table Depth-----------5--------------------------------------Rock <br /> Size------_ r t _ <br /> Distance to nearest: Well---.---_ ._ . r -- l7!?-'_ <br /> I ------------- -- Foundafiori{ � P'rop`Cine---- ---------- -- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date___--_--_ _ .- ) <br /> Septic Tank (Specify Requirements)______________ ______ <br /> - <br /> Disposal Field (Specify Requirements).-- --------------- - _ 4 <br /> - -------------------------------------------- t-- -- --------------------------------------------------- ------ <br /> -------------------------- <br /> ------------------------------------------------------------------ <br /> -------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be d-ohe lin 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: f <br /> "I certify that in the performance of the work-for which this permit is issued I sha11 not employ an <br /> f p Y y person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> -� IvLAREIt:'g; SEPTIC SEWER SERVICE <br /> Signed'---- ---- Owner ?6 Si.'0 <br /> �j/� -. fQ Stacktoil. Calif. 95205 <br /> BY - --- ---- --------------------------Z_ 7 Title.------ Ph.4.63�3Zo <br /> {lf other than o l -- 01WA,CIVSkiC42&7171- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> BY—E <br /> ----------- - �------------- --------- --- -----DATE _..--- ---��� ---- - <br /> ----------------------------------- <br /> -------------------- <br /> ISION OF LAND NUMBER-------------- DATE. <br /> ADDITIONAL COMMENTS---------------- ----------------------------------------------r___-- --_-__-- -- <br /> ------ V---------------------------------------- - �` <br /> ------------ <br /> -------------------- -------------- <br /> ----------------------------------------------- <br /> t <br /> ��- -------- <br /> Final Inspection by:----- -------- ------------------------ Date.- .-.--_-_ r <br /> ---- -------------------------- <br /> EH 13 24 �. ,,. _.�_. ._. _ _ •SAN JOAQUIN-LOCAL HEALTH-DISTRICT_- ,T F&5 21677 REV. 7/76 3M <br />