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FOR OFFICE USE: - FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 7 <br /> - (Complete in Triplicate) Permit o.................. <br /> r��7 <br /> -0� ...........___� <br /> -----------_____________-......----------------..._---- This Permit Expires 1,Year From Date Issued Date Issued-..b <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 compliancewith County Ordinance No. 549 and eiiisting Rules and Regulations: I <br /> _ , <br /> JOB ADDRESS/LOCATION..--:.__ '�f... '_.R ....-..CENSUS TRACT...._.. <br /> Owner's Name _ __ �..---..t= / 'y-:` - D / .� -- --------- ------;--4js�Phone <br /> ./-._... , ltJ/--- - CZE Cit .. <br /> Address-------- _ _. . �., ,. y � fJ 1-1 --------Z ---------- <br /> Contractor's Name- ----- .--- -- f .-------.-- - <br /> �- � �L-�- ---•--=------=---- --License <br /> Installation will serve: Residence ❑{ Apartments House ❑ Commercial ❑ Trailer Courit ❑ <br /> Motel❑ Other-=-'- .. --------------------- ,._ :J- <br /> --- -- �'}t <br /> Number of living units:-__ -- ----Nurriber.of bedrooms '_ Garbage Grinder ' Lot.Size--- _ _ ---'f-- --- <br /> Water Supply: Public System and'name------------- <br /> -- -- °h ' : :`.-__,-- = ---- - - -==-= Private <br /> Character of soil to a depth of 3 feet: Sand 0-I Silt R. Clay" Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> t6 <br /> .Hard Zn Adobe, FiilMaterial' ..._.......ff yes, pe----------------- F <br /> (Plot plan, showing l ize of lot, locution of system in relation.to wells,buildings, etc. must be placed on reverse side.) <br /> NEW 'INSTALLATION: <br /> (No[septic rs.eepage p�p, ttd��ubiic sewer is ��th32� f ) <br /> REATMENSEPTIC TAN'K4-6 <br /> - - LiqidDepth �f!ZKAG Size - <br /> Capacity "r)------TYP�I'' `I Material- '= -.No. Compartments------------ -----� <br /> [ Distance"to nearest: We -----------------Foundation...1s ._.- .___. :__,Prop. Line__._ - ----- <br /> ------------ <br /> . of Lines --- --'.'- Length of eachline....... � ----------=-------Total: Length.;-�`�...'�.------------------------ <br /> LEACHING LINE [ ] No. . . , l iI <br /> Box- ----.---Type Filter MateriaDepth Filter Material------- - ---------------------------------------------" Im <br /> Distance to nearest:-Wgll _10 ------ ..---Foundation- --------------Prop&rty Line----- ---_____.__.__+ { <br /> t <br /> SEEPAGE PIT [ ] Deptht7�ti?-----Diame-er-' . ..--Num♦3er. r Rock Filled Yes' No 0 <br /> -----= ❑ <br /> Water Table Depth- = <br /> / ------ --- <br /> ' � -= --------------- ----------------�� ---Rock Size------- �• <br /> Distance�to nearest: ------ ------ ,-- Foundation---------______s._--�`_-Prop, Line--.----_'---------------'--- <br /> REPAIR/ADDITION { rev-Sanitation Permit#!- --------------------------- ----°------4-J.-Date------------------- -------------------- <br /> Septic <br /> ---.-------------Septic Tank (Specify`Requirements)----- -Ur --------------------------------------- -------- ---------------------'----- I------------------------------ ----------- ----#--- <br /> Dis osal Field (Specify Requirements)' ] <br /> p .2 p � Y q <br /> 1 - _ <br /> -------------------------- ------------------------- ---- - ----=--- -------- -------------------- ------ ------ <br /> -------------------------------------------- <br /> �� of <br /> -------=-------------------- ----- ------ <br /> � � ---s existing and required addition:-or'1` reverse <br /> ----------- <br /> (Wal", ide) <br /> I hereby certify thatil have prepared this application-and-that--the�work willbe•-don' in accordance with San Joaquin County. <br /> Ordinances, State Liaws, and Rules and Regulations of the San Joaquin Local Heplth District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of'the %6rk for which this permit is issued, I shall'not employ ny person in such manner.as <br /> to become subject ;to ans Co <br /> r ' l <br /> l pegs ion.,.,laws_,,of_Cali_forpi,a;>" - <br /> Signed-- L = �"; t----- Owner <br /> ------------------------- <br /> r <br /> $Y :------- --------------------------------------=----------------.------------------------------- .Title ----- ----- --------------------------------------------------- <br /> (if <br /> ------------- - ---------------------_----- <br /> (If other than .owner) <br /> FORDE ARTMENT'USE ONLY' r <br /> APPLICATION ACCEPTED BY.: - ---- --------------------------DATE - - ---------------------- <br /> DIVISION <br /> --- -- - <br /> DIVISION OF LAND C, UMBER---- <br /> ADDITIONAL COMMENTS. = ¢ --------------- <br /> . .,, a <br /> ---------------- <br /> Fina ---------------- ------ ------ -- ------ <br /> 1 <br /> I Inspection bY----------- -���- _ ------------------ - - ---..._Date--- ---- -- - -- -- ---------------.--- I <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 inn <br />