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1 Ott�7FFIClr-US'E �' <br /> APPLICATION FOR SANITATION PERMIT permit No.?/7:i --- <br /> s-�y-�r-___/a,'-00---------- <br /> ______" _ (Complete in Triplicate) <br /> - <br /> c Date issued <br /> 9 This Permit Expires 1 <br /> Year From Date ssue_ <br /> —. — _ <br /> ---------- --------------------------------------------- <br /> ( 5' 76 <br /> 7" <br /> Application is hereby ml the work <br /> h S n nom�lianCecan+ith County tO dinarnce Nom5�l9 and existing dukestalndegulations,e,n <br /> described. This application is made p 41rb4 <br /> ATION <br /> JOB ADDRESS/LOC ----- ; <br /> '_ (l �-------CENSUS TRACT -------------------------- <br /> Owner's Name - - -`��`-----�-- -----•----------------------- -- <br /> Phone._ �7T- � <br /> --------- <br /> - City --- ------- ------ -------------- ------------------ <br /> -- ---- ----- - <br /> Address ----- - ----------- ----------------------------=------ --------- --------- ------- �D ---:� �l Phone <br /> ense # "--- <br /> - <br /> Lic -- <br /> Contractor's Name --- <br /> Installation will serve: Residence E] Apartment House❑ Commercial ❑Trailer-Court 0 <br /> k Motel El Other ------------- - - �� <br /> �of6ize --- a --•--•-•--- <br /> Garbage Grinder __-------�-- .. <br /> Number of living units:. Number of bedrooms __________-- Private ❑ <br /> Water Supply. Public System and name ------------------- ----- D._ , , ,-�r Clay-Loam ❑ <br /> Silt <br /> Clay' Peat❑ Sandy Loam ❑� Y' <br /> Character of soil to a depth of 3 feet: Sand'[] ❑ ,_Yr ❑ <br /> p M ± `------------ ---------- <br /> Fill if t � <br /> Hardpan ❑ Adobe <br /> 1 buildings must be placed on reverse side.) <br /> {Plot plan, showing size of lot, location of system in relation to wells, A <br /> p p g permittedpublic sewer is available within 200 feet,} <br /> t <br /> NEW INSTALLATION: (No se tic tank or�s�ee a e.pitSize _If_ -` ------------------------ Liquid Depth ""------- ------------•-- <br /> SEPTIC.TANK''[J: <br /> PACKAGE TREATMENT [ ] t No. Compartments <br /> ll <br /> ---------------- <br /> ------------ <br /> -S, <br /> ----- <br /> -----------t• TypeMaterial <br /> Capaci - <br /> Tf-% n�eaes : Well -------- - -- ----------Foundation ------------ -------- Prop. Line ----------------•----- <br /> ------------- <br /> Distance <br /> --�,__--`___-- Length of each line---------------- ---- ------ Total Length :------- <br /> LEACHING LINE [ ] No. of Lines ------- y <br /> I _------- Type Filter-Material --------------------Depth Filter Material ---------------- <br /> D' Box <br /> Property Line <br /> Distance,to nearest: Well ___----------------- <br /> --- Foundation ------------------------ p ty ------------------------- <br /> Distance, <br /> ------•--- ----------- <br /> SEEPA(PIT [ ] Depth - ----. <br /> Diameter <br /> -------------- Number Rock Filled Yes El No <br /> Water Table Depth ------------------------------------------------Rock Size - <br /> (ti _ Foundation - ---------- Prop. Line <br /> '. -------•------•----•-- <br /> Distanceto nearest: Well ------------------------------------ ------ <br /> [ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- <br /> Date --------------------) <br /> --------------- <br /> Septic Tank [Specify,Requirements) ------------------ i " <br /> / <br /> ---- -------------- <br /> - <br /> Disposal Field (Specify Requirements) ----------- ----•-- <br /> ---------------------- <br /> -------"-------- <br /> ---------------------------------------\---------------------------------------- <br /> -------------------- ---------------- ---------------------------------------- <br /> - <br /> ---------------- ---------------------------------------------------------------- ---------------------- <br /> ------ ---------- ----------- ------- -----�.----- ------ <br /> -- <br /> (Dra-w existing and required addition on reverse side) <br /> - <br /> k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> I sed agents signature certifies the following: person in such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> as to become subject to Workman's Compensation laws of California." <br /> # Signed ----------------- ------ -- ---- --- -- - ------------------------------------ <br /> Owner <br /> - - ---- ---------- <br /> --------------------- Title ------ - ------ ----------------------------------------- <br /> (1 ofiher t owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE - - ---- ------------- ----- <br /> APPLICATION ACCEPTED BY __ -----------�------ ----- DATE ------------- <br /> - "--- <br /> BUILDINGPERMIT ISSUED -------------------- ------- --- - ----------------------------------------------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------- - ----------------- ---- <br /> ---------------------- <br /> ------------- <br /> ---------------- <br /> ----------------------------------- --------------- -- --------------------------------------- ----- ---------- ------- <br /> - --------------------------- --------------------------- ----------------------- <br /> ----------------------------- ----------Date <br /> ------- ------ <br /> -------------------------------------- <br /> Final Inspection by: " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s <br /> I F. H. 9 1-'613 Rev. 5M <br />