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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------- --------------- Permit No... <br /> {Complete in Triplicate} <br /> ----------------- <br /> Date Issued_.�_��."�4 <br /> � - This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Heolth 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 Regulations: <br /> N.._.F. '_ _ N JOB ADDRE55/LOCA710T4 <br /> Owner's Na-me._..----: -tJ------ 1 :_:: Pho �.3 <br /> ---- - ----- -- -- <br /> Address ------------ -��C---------------------- -- -.`-- t City` j�J��' zip <br /> — / <br /> Contrc�tor's Name-------- +IE-+-- ------------------------------- -- - -License #�-= ---Phone------- . <br /> Installation-williserve:� fr RApartment. House.[E Commercial E] TrailerlCourt E]4_6k, <br /> idence <br /> Motel L] Other---==---------=-- '--- ------ - � 1 <br /> Nuimbe of living. units:__ __..:._____Number of.bedrooms :--_Garbage Grinder:..,__.._.__Lot>Size�- , <br /> -----------------------��r <br /> Water upply: Public System and name---- ----------------------- ---------- -------- --- ------------ =-------- -- �Y _:: Privat�l" <br /> : , <br /> Charac er of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loa pe 0-.0 <br /> C}�y L am FiIIMaterial__.._-__. _-if yes, tyHard an Adobe ] <br /> -)Plat plan, showing size of lot, location of system in relatio o we Is, buildings, etc. mus?e �c1ced on r vZe side.) I <br /> I � <br /> NEW INSTALLATIONc [No'septic flank or seepage pit p Atte if public sewer Ls ava7ab'a within 200 feet,} <br /> ` f.. ._- ° --------Liqu'id Depth--- ------- e <br /> PACK GE TREATMENT Ca ac tPTIC TANK T ; <br /> p y_ _ L YPe a No. n#�s. <br /> r: <br /> ... ......=„--w- .. <br /> Distance.to nearest:.INeIL;=.-_... .._.,._ ...._._.'__-_ .%----- -_ Found, --- --t Cp-i�ft , - <br /> tenial <br /> anon s t_ nop/ in ----- --- <br /> LEACHI G LINE, [`.] No. of Lines-- --�4_-, _`__ ____.__. eng�h of each line,--- .__.-__- _____,T�tal' <br /> Len th ___.__ ___ '. <br /> . .,.,... <br /> 'D' Box Type ,ta eria!_._- Depth Filfer Material - __ .__ <br /> - ------- l._.. -- -- --------------------------------- <br /> j <br /> Distance to nearest: tit=__ ____° Foundation.__ Proper line _ :. <br /> SEEPA E PIT [ ] = Depth----------- ----Dia ete ,----_-----------Nur bet . '--•-•�—r"i o Fi Yes ❑ No E] <br /> Water Table Depth -'� -=------------- - = .ati .. F } <br /> { �f. <br /> Distance to nearest: Well_- _y ----- `------_-- ------- Foundation-' ------ -- -- ------- Pr p` )line '__________-_______-- .. <br /> REPAIR ADDITION (Prev. Sanitation Permit _.__T____..:------_-------__ _R a e [ ------ <br /> Septic <br /> ----- <br /> Septicank (Specify Requirements) i ' ---=------------ # - <br /> � f <br /> p Y' - --- _. <br /> r._ f,T ^^ _:_ >�l �tJ----------- <br /> pas I Field,[Specify Re .A_�w____._ E--- <br /> Dis ] ------ ------------------ <br /> -------- <br /> - -- -------------------- <br /> --------------- <br /> : {Draw existing and required addition'on reverse side) <br /> I hereby certify that'] hpve prepared this application-ant that-th'e-work'v il-be-fbivu—in accordancvwAaan Joaquin'County f. <br /> Ordinances, State Laws, and Rules and Regulations af 'the San Joaquin Local Health District. Hoe owner or licensed agents <br /> signature certifies the following: <br /> "I certi�Fy that'in the performance of the war for whit this permit is issued, I shall not employ a y person in such manner as <br /> to become ssuubbject t or an's Compenscittion laws of California.':..-.. i <br /> i <br /> Signed _---- - ... j i <br /> BY-1 -------t -- -- -- itre` -------- <br /> -- -- .- <br /> jl'f other than towner} s. <br /> I FORiDEPA MENT USE ONLY' <br /> APPLICATION ACCEPTEDrBY_;-'_ ------- DATE ..... <br /> ' -- --- ------------ <br /> -- ----- <br /> -------3--- <br /> DIVISION OF LAND N.UMBER._- ---' ---- --------- ----------------- --------------------- BATE - <br /> ADDITIONAL COMMENTS ------------------------------------------------- -------------- ---- ° <br /> --------------------------------- ----------------- --------- ---------------------------- -- ------- ----- --- ----- ---------------- ----------- <br /> -------------------=----------=-------------------------------------- -------------------------------- -------- ----- --------------- ---------------- <br /> i ---------------------Final Inspection yby - ”l -== . ---------------------��� <br /> Date <br /> �-- d 'la = <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />