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FORT"OFFICE USE: FOR OFFICE USE.. <br /> • APPLICATION FOR SANITATION PERMIT <br /> ---- ---------------------------- ----------------- Permit No..-`��7r�_ <br /> (Complete in Triplicate) --.--.�- <br /> ---------------------------------------------------- <br /> Date Issued.. '.��_.7-- <br /> ----_-_-_-----_-_----------_----- --- -------- This Permit Expires 1 Year From Date Issued <br /> ft pD zT - o�©-- <br /> Ap��,—C?a*—n is here y m dd t'a the San Joaquin Local Health District for a permit to construct and.instal the work herein described. p <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: b <br /> JOB ADDRESS/LOCATION : - Y - -------- CENSUS TRACT------=----- - ------------ <br /> Owner's Name- ---- --- ----- ---------- -----.Phone----- -------------- ------ _ <br /> Cit . `----------- --- --Zip----------------------- <br /> Address---- --- 2fil -� Y <br /> Contractor's Name --------------------License #_o;7 Phoneys S-.z�/�. <br /> Installation will. serve: Residence E] Apartment House.E] ,Commercial ❑ Trailer Court El <br /> Motel Q Other--- - ---------- ---------- ---. ------ <br /> Number of living units;---- --------Number of bedrooms',/. Garbage Gri der__ --------Lot Size... - ---------------- -=- -,--- <br /> Water Supply: Public System and name = R` <br /> 9 ------------------Private'❑ ~I <br /> Character of soil to a depth of 3 feet: Sand [J4 ,Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay Loam ❑ � <br /> i Hardpan ❑ AdolSe ❑. Fill Material------------1 yes, type-------------------------------- ` <br /> (Plot plan, showing size of loft, location of system in relation to wells, buildings, etc.tmust be placed on reverse side.) <br /> NEW INSTALLATION: '(No septic tank or seepage pit permitted if ublic sewers its available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK [ Size_. Lf�1 - -^- e�--------- ----Liquid Depth . -------------------- <br /> Capacity-/ ---- <br /> ./`2-------.-,L--- ) <br /> [') <br /> Capacity -A t) �_ No. Compartments ----------- ' <br /> Distance to nearest-Well--------- -- F�dat.ion,,_ ___.----.Prop,CLine.�. <br /> Total Len th.= CLQ - <br /> LEACHING LINE [e No, of Lines-------- <br /> h line.. .___ 9 <br /> Type ept Filter Material..... __ <br /> D Box..,-.--- ---T e Filter Materia ---- ------------------------ <br /> --------------------- -- <br /> F / <br /> Distance to nearest: Wel I._ '___..Foundation__. .................Property Line.....s---...-.....___...-..... i <br /> SEEPAGE PIT [ ] Depth----------------Diameter--------_'------:----Number--------------------------------- Rock Filled Yes E] No ❑ ' <br /> Table Depth = - ----------------------Rock Size------------------------------------------------ <br /> Water <br /> Distance to nearest: Well. -- -----------------:- -----------Foundation--------------- --------.Prop. Line----------- <br /> . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------=---=----------------------Date---:---------.-------------=------- ---r------) <br /> Septic Tank (Specify.Requirements)---- --- -------- -- --------------------------------------------------- <br /> Disposal Field(Specify Requirements)----- ------------------ --------------------------- ----------------- --- --------- <br /> --'-`------------ ----------- --------------------- - - ---------------------------------------------- - -- <br /> 4 r__� - -------- -- ------------------------------------- - - <br /> . <br /> - --- - ----- <br /> (Draw•existirig and required addition on reverse side) <br /> I hereby certify that I have prepared this.application and that the work will-be-done ,in accordance with San Joaquin County J <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: <br /> "I certify that'in the performance of'the work for which this permit is issued, I shall not employ any person in such manner as <br /> to becorr bi ct-toorkm n's.Compensation.laws.of .California.' <br /> Sig u = = Owner <br /> VothJ ---.Title -------------- ---------------C� <br /> r than owner) ! <br /> FOR DEPARTMENT USE ONLY " <br /> '' = --~'--------------- --------'DATE - �.:.��"'-�------------- <br /> APPLICATION ACCEPTED BY--------- -------------------------------- - <br /> DIVISION OF LAND NUMBER, ---- -- -----------—-----:--- ..----- r DATE <br /> ADDITIONAL COMMENTS--- / x .N ..0 �aG�.�--- �-m--wue - v��--------- -- ---------- <br /> I <br /> ------------------------- ------------------------------------ -------------------- ------------------------------------- <br /> �-- ---------------------- - - �' <br /> Final Inspection b -------- --Date.--- ---7 -- ---------------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M <br />