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5 <br /> FOR OFFICE USE: _ FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------•----------- .......... ............. ; <br /> (Complete in Triplicate) Permit <br /> ----------------------------- - --- ....... I <br /> Date lssuedlC -La.�J$� <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.complia.nce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA TION .ter k 0....�1 ./ Oa .. I �'h --.CENSUS TRACT-------- -- --- <br /> Owner's.Name. L I^I^rt �d f..... -__.... ...Phone-------------------- ........ <br /> , % dr T <br /> I .v J/ vc <br /> Address -- .----- D rs-_ City-- -�a.. .�a/11.°'. . --- -_... ..Zip-�-. ---- -------------•- <br /> Contractor's Named ...!�. ._-41.C/e_ll 4 1. "t' ��1".✓� [ �._.... .License # `. ° Phone <br /> t <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial N� Trailer Court ❑ <br /> Motel ❑ Other............ . ................ <br /> Nun ber of living units: ...............Number of bedrooms........ Garbage Grinder-------------Lot Size----------............ ...... ----.................. ..---- <br /> Water Supply: Public System and name..... ...............•.---------.--.----_-.-. ; ------.Private ®' <br /> Y � <br /> Cha"racier of soil to a depth of 3 feet; Sand ❑ . Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Rr <br /> Hardpan g Adobe ❑ 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 feetJ) <br /> PACKAGE TREATMENT G�� ^�----•---:------ i !G y <br /> [ j 'SEPTIC € Size - - -.-/- - _-_S- -- - --------------Liquid Depth.----- ---...... <br /> Capacity.,G w-----..-Type�l"PLlta� ... Materrial.Cz74?,—'.r .P-._No. Compartments---------­­--------­-- -- <br /> LEA Distance to nearest: Well------- . .............Found ------ <br /> INE <br /> ---- Q I Length <br /> Line._._.? __...-.-:...� <br /> LEACHING LINE 4N o. of Lines - ' --.. .- ....... Length of each fine...---..-(� - _- -- -- gih k �•-74.,. } <br /> I 11 //'' <br /> 'D' Bax_ _� . . Type Filter Material.$%j,-O� Depth Filter Material------Lg....0 ----- ------------------------------ ---.� <br /> � Distance to n�arest: Well---,=--�.�.5-� --�......Foundation--.--�-L'D-------------Property Line...... ---�.._..:._----..... - O <br /> .,� iw i <br /> SEEPAGE PIT ) Depth __.2..�_____Diameter..:.Lf_.--XL4=`_ Number------------�-- .._____ .. Rock Filled Yes No <br /> Rock Size.-.-/.'... .E.�............... •---- <br /> Water Table Depth.'_. -�, t=r- . --- / <br /> Distance to nearest: Well .._._ Foundation.-.-__- ,d_........Pro Line._Js.................. <br /> •f l€ . xS.,0 t-----..-- . �� p' <br /> REPAIR/ADDITION (Prey; Sanitation Permit#----.---- .----------. ----------.Date:........................................_...) l <br /> Septic Tank (Specify Requirements) ------ ------ ---- -- ----------------------------------- ------------ -- -- - ----- -------- - .... <br /> Disposal--f=ield-(Spec _y,,Requirem ents).-- - - -----.- ---.... ....... ............... ----------- ----- - <br /> t <br /> ' 3 ---_-.----.- -.. <br /> y --------------------------'...._....:__...... <br /> I _ _ --------- ----------- --- -- i <br /> ... . ---------------- ---- ---,-- ----- ------------- --. -.. t- - r <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify.:thdt I have prepared this application and that the work will be done in accordance with San Joaquin County 3 <br /> Ordinances, State Laws, and Rifles and Regulations. of the San,Joaquin Local Health District,.Home owner or licensed agents <br /> signature,certifies the following: s <br /> x <br /> "I certify that in the performance of"the'work forte' hicti--this permit is issued, I shall not employ any person insuch-m nna eras <br /> to become subject to Workman's Compensation laws of California." l <br /> ,a a <br /> Signed. -- -- ---- :_f_.....-.. Owner <br /> BY... / ...��. ..... .... .... . .•--------- -4 .......... Title.... <br /> t �.. ................. <br /> (If other than owner) $ <br /> . _ FCI DEP RTMEN E Oyly <br /> Ny... ATE.....° - - ..... <br /> APPLICATION ACCEPTED BY :— -- ---- ---------- ---------------. D <br /> DIVISION OF LAND NUMBER--------------- - -- --------------- ---------- - - -----.,...--------------------------- DATE.-.. <br /> ADDITIONALCOMMENTS........ ....... . ..... ----------------- ----................. . ......... --------.............. -----------­ ........---- ....._ .....-_.. <br /> ---------------------------- ------------- --- ......... .....--------...-- • -- ----- -- ---.. .. ...----.----. •-- ---....---- --........... . ------- --- ----- ------ - ........ <br /> -------------- <br /> ----------- ............................. .... _.....--- _-..-..----------...__.-------..._.. <br /> --_. _.._.__.._.. _....._ <br /> -------­---------------------- _ _ _ ' ..... ---- --- __------- <br /> . I <br /> Final Inspecr,on b Date.-.--/Q- 3i_1'f ... i <br /> FIA13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 aev. 7I76 3M 1 <br />