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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------- <br /> (Complete in Triplicate) r Permit No.7_._.-_ SoL <br /> -------- - -------------------------------------- <br /> ------------------ -------------------------------------- This Permit Expires 1 Year From Date Issued Date Issuedl/`15�72 <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 Regulation <br /> JOB ADDRESSAOCATION---------C -. G d!^ S IS t t- .t,...r �� <br /> - y ---- .......­----CENSUS TRACT------------------------ ........ <br /> Owner's Name------�-�^. <br /> �.lR Y RE! = - ---_:- --_ ---.- -:--- -- -:-- -..------=-Phone � <br /> Address ----ss.- --- City <br /> y� <br /> 9`,: = ���� -/ rv_`_�`= --- ----zip - <br /> Contractor sName---- ;;. �.-/Tfi------- '�J .__..__--;� ---------------License #_wlLJ�O__ Phone-- `�__O___ __7__ .---- <br /> Ins'tallation will serve: , Residences; Apartment House �_�ommercial L] Trailer Court: ❑ <br /> -� Motel L Other___ <br /> g <br /> Number of�ivingn _________________Number of.bedrooms_-_____ Garbage Grinder___:_.______Lo 'Size_. _ ------------ <br /> V <br /> _._____ <br /> Water Supply: public System and name_ _---_- '-- ----- -----= - -- F. -- � ---------- ---- € Private <br /> { [ t _.. _ I <br /> Character of sail to a depth of 3 feet: ' Sand E] :Silt ❑ Clay ❑ Peat❑ Sandy_i:oam ❑ Clay Loam <br /> —}` Hardpan ❑ : Adobe ❑ Fill Material - yes,yes, tyP� r <br /> � 1 <br /> [Plot plan, showl�ig size of lot, location of system in relation to wells, buildings, e4'1must be placed on reverse side.] <br /> NEW INSTALLATION: '(No 'septic fa' nk`or'seepage'pit permitted if public sewer is available within 200 feet,l i. J <br /> PACKAGE TREATMENT [ ] . SEPTIC TANK =:----:-- ----Liquid Depth...__.- f �j <br /> t��Py <br /> r r ----.____' _ <br /> >_ a = Material------->. --------: No. Com artments--------- --------------------------- <br /> -to <br /> ---= ----- - ---- --- <br /> Capacity = P P <br /> 'Distance to nearest: We <br /> -------=------------------- - 'Foundation---===----------=---------Prop. Line ;= <br /> LEACHING . INE' [ ] No. of Lines =:.-.--:-.------- ---------------Length of each line Total <br /> • Length. -------- <br /> C <br /> =.D. ....ox__,.�__ .-____T-yp,,.e._Fi�lter-M- ate_»r..ia._!._.,_..__.-_.� Depthth Filter <br /> r._Ma.te.rial--=------- ----------------------- I- <br /> Distanceto nearest: Well------- ____.Foundation _� - � `_ Property Lin - -- ---------------' <br /> - <br /> 5I <br /> � <br /> SEEPAGE PI,T <br /> a Diameter---------=------=----Number----------_-E -----------_-'- Rock Filled Yes ❑ No ❑ <br /> [ ] Water Table Depth--- - ;Rock Size;--- = = <br /> p ----- <br /> Distance.to nearest: Well ` ` r --- -------Foundation--.-------_---------------Prop, Line -- ---------- <br /> REPAIR/ADDITION <br /> --=-----REPAIR/ADDITION (Prev. Sanitation Permit#---------._------------------ -_--------------- :Date------------------------------------------------ <br /> Septic <br /> --- -----------_-------Septic Tanki(Specify Requirements) ------- ------------------------------------- " 'rn' ------------ -----'------------------- E ` <br /> Disposal Field (Specify Requirements)_.__ ✓, c, � y- f -_`_-_ ("A- '--- <br /> € - -- <br /> -----=------------- - ---------------- - -- --- - ---�---r <br /> ----------------- - - _.__ <br /> ----- ___. _I______________ ------------- <br /> Y, <br /> Y _ <br /> nd <br /> I hereby certif that,_have- re ared..thDraw application.and that fired additian'on reverse side) <br /> + y y . p p pp f the-'work will be done in accordance with San Joaquin County <br /> Ordinances,1,State Laws; and Rules and Regulations of the Sari Joaquin Local Health Distri t Home owner or licensed•'agents <br /> signature certifies the following: <br /> "I certify that in th'w performance 6Vthe'work for which this permit is issued, 1 shall not employ any person in such manner xas <br /> to become ,sublec o.. ork s Compensation la Ws of California." <br /> Signed. ti ��J-- - - ------ - Owner ' <br /> BY-#------ ---- --- ---------------------------------------`-- -- '.Title--- ---- ------ ------------------ ------- --- <br /> (If other than owner) ` <br /> FOX DEPARTMENT USE ONLY',.; <br /> APPLICATION ACCEPTED BY--'--- �. -- - -: - .- - --DATE.------ -- -- ------------ -- <br /> --- - - -- -----=-------- <br /> DATE------------------------ <br /> DIVISION OF LAND NUMBER-------==---------------------- - - -----------------------------------------,-- ---}----------- -'--- <br /> ADDITIONAL COMMENTS----------------- ------------------ ------------------------ <br /> 4 • ___ <br /> - . <br /> - ---------- <br /> ------------ <br /> Final Inspection bY= �;. .`. . ._ ._ Date:.___ .-:-� '--- ---------------------------- - <br /> -------=--------- <br /> . .: <br /> EH 13 24 CAL HEALTH DISTRICT F,&5 21677 REV. 7/76 3M <br /> °y. NI-1 14 r <br />