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FOR OFFICE USE: X11 <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ------------------------- --------- --------- <br /> (Complete in Triplicate) Permit No..-',.z .9 <br /> """ --' <br /> ' -.-'--••-•-� ��- - Date Issued... <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, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION/f- ---Al -fi4C <br /> ..............•----- <br /> Owner's Name... <br /> �— -GE1StJS TRACT --------------- <br /> --- - ---- .. <br /> � + <br /> ... .: ....._ ...... f ---Phone._ <br /> Address----- t! <br /> # `✓ Z i <br /> Contractor's Name.. ...- --._ app 3�- <br /> � .,v.._ rr�ST --•--- License # Uf1- .--- Ph:on <br /> I <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> ___.....M..o.tel❑ Other_...-.....--. ----------------------------- <br /> Number <br /> - �------=--- <br /> ------- <br /> Number of living unfits;_./ .. Number of bed oGrinder--,09� Garbage ...Lot Size----�.. <br /> Water Supply: PublicY and name <br /> l <br /> ....................................... Private [� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt,❑ Clay ❑ Peat ❑ Sandy Loam E] Clay Loam E] <br /> Hardpan ❑ Adob . 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 pis available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size_' ...--------Liquid Depth..:_- j:-: <br /> _:-----------------=--- <br /> V., / . � <br /> Capacity .------ ---.Type....i.......-- ...Material-`r- --- ----- i fNa. Compartments---------•------ . ----- <br /> ' <br /> Distance to nearest: Well..------i-------- <br /> Foundation...Z.s..... . ...Prop. Line------------........_... <br /> ..4 J <br /> LEACHING LINE I I r <br /> ( l No. of Lines. ----- #Length of each line--------- -- ----------------- Total Length ......... •--...............----- <br /> 'D' Box...:.........Type Filter Material.......- -----.Depth Filter Material....--..-----.-.---,- - <br /> ._....--.__- <br /> ---- ------ <br /> A.,. <br /> Distar cE> o nearest: Well ---- ---- ..... ......Foundation.............................. <br /> Property Line_.---:------- . . . ._...--------. <br /> .-.-------- <br /> SEEPAGE PIT ) ] Depth...... -Diameter'_--- -.i _1 <br /> - N-umber�.:... I__.' Rock Filled Yes ❑ No ❑ <br /> Water�Ttib1_6_�,Depth ,r-: ...... ° -_---------------Rock Size-- -'----- ..:....:... <br /> ---------------- <br /> # -- --- ----_--------------Foundation ........__.Prop. Line------------- .... ... a <br /> Distance to nearest: Wall.-......."'.-F. . <br /> REPAIR/ADDITION+{Prev `Sanitation Per.mit#.--"` "------------------ ppte_.-..._. -..--------------- --- } <br /> , i <br /> Septic Tank (Specify Requirements)--------- •.i = i-------- { <br /> A� iiA TJ- ty,�! / <br /> Disposal Field (S eclfy Re quirements)..fe ..... .../_0 :_dr�I AC' W,r�jiLLa _._.t <br /> t <br /> ?2 _ .�,S7/7 7X 0 t =`-------------- ------------ ----- <br /> ..... t-...........:................................ .................. <br /> ... <br /> (Draw existing and required-addition on reverse side) t <br /> I hereby certify That I have prepared this application and that. the-work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, an' "R hl i and Regulations of the`�San- 'Jaaquiin& il_Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> x cy <br />"I certify t~a��in"°t performance,of the work for whicirlthis permit is issued, I shall not employ any person in such manner as s <br /> tobecome sub to Wcrkma ompensation laws-of California." NJ <br /> Sig ned--- ..... Owner <br /> ---- ------- i <br /> r th n, ner) , <br /> ,FOR DEPARTMENT USE ONLY ! <br /> APPLICATION ACCEPTED BY - DATE <br /> DIVISION OF LAND NUMBER--- ------ ------- ....... DATE. .. <br /> ADDITIONAL COMMENTS...h,�C - ..�+.4� .. -------- ----- ------ -- - <br /> -----••------- ------- - --- ------ .............. ..... <br /> -•--------••------ - ------ ----- I——----------------- ------ ------ --- - <br /> ... <br /> Final ----- ----- -- - - - ------ --- --- ---------------- <br /> Fina 2Inspection by:.. Cil ------ ---- ------------------------ ---- ------ ---•-------------------•-------------Date- Z3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />