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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR'SANITATION PERMIT �7-73, <br /> Permit No------ --------- - <br /> ----------------------------------------------------- (Complete in Triplicate) <br /> ---------- ------- Date Issued_.------------------ , <br /> 4 This Permit Expires 1 Year From Date Issued <br /> _ <br /> Application is herebymade to the San Joaquin Local Health Di`strict-for a+,permit to construct and install the work herein described. <br /> This application is mde in compliance with County Ordinance No`549 and existing Rules and Regulations:_ N <br /> JOB ADDRESS/LOCATION..,:._3.. �� 3__- --`----��7--- - -`� 1 ` --------' -*­­1___CENSUS TRACT <br /> ` - �T' Phone <br /> Owner's Name- -- - •--- :�-- ------- i� <br /> :Y�;3 ,�c ---- ----- - --------- <br /> -2,3 <br /> - --- <br /> ! : <br /> Address--- <br /> c <br /> [7� zip . <br /> ts — one----- ----------------- <br /> Contractor's Na ? � �). _ ! ------------------------ ------------- <br /> I fY __? License <br /> fG �� Ph` ;�,� . <br /> 7 1 <br /> Installation will.serve: ResidenceXA' artmenf House [I Commercial E] ;Trailer Court E] [ <br /> Motel; ❑ :. .. . _ -- - <br /> ..� -Other-- '•-- -------- �- <br /> 1 <br /> --- ----------------------X. <br /> Num ber of living units------ ---------Number of bedrooms' -3"_._.Garbage Grinder.. Lot Size `r _ y <br /> Private <br /> Water <br /> Water Su 1 _ Public System and home------------• ---- <br /> f <br /> Character of soil to a depth of 3 feet: ' Sand El Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ¢ <br /> Hardpan Adobe.❑ Fill Material-_ ------If yes, type.---___ --------------------- <br /> ells, <br /> -. ----- --- <br /> i, <br /> (Plot plan, sh ing'size of lot, location of system in relation to.w ells, buildings, etc. must be placed oh reverse side.) <br /> . No se tic tank or see a e pit permitted if public sewer is ova�lable within 200 feet,] <br /> PACKAGE TREATMENT ] ] SEPTIC TANK [,] Py;g' f Liquid Depth <br /> ., <br /> l f Size : <br /> ] .2G _-s 1 <br /> P Y yp ��`�` CHS Matarial_ _Ca%li�G - -Compartments--; <br /> Ca acit _ T e_.-____-_-_-- No: __-- <br /> Y "---__-""---_ <br /> S � j <br /> ` Foundation-_[_-- _. -�- -Prop. Line_--�- C� <br /> r , Di'stance;to riearest:.Well..: _'__:_�--------------- <br /> A <br /> ---- <br /> FAT.>61- , j� , , , ------------ -------------- <br /> L � i # ��' - -De fih Filter M:_:: _Total Length. <br /> YP ,,.Length of each line- al_.z-_,:_4y ---- ----------------------------------= <br /> ` ., -- P - <br /> . <br /> WJE [ ] Na, of Lin_es___________ ___ _ en <br /> aten <br /> Qistanceo nearest Filter <br /> Mat - �,.�'' ! . . _ - ------- ------ <br /> r _; Line----- <br /> • - --- <br /> . on „ <br /> -- .. ....,tet. ._. ... .. ._.._. .. r Foundation- <br /> . <br /> + tl ; • - <br /> N <br /> Diameter_ - -----Number------------------- ed Yes-F] <br /> SEEPAGE PIT [ ] Depth, ---- .rRock.F� o f <br /> i . i <br /> Water Table Depth- :-------------------------- ---- -- ------ z i y <br /> ----------------- <br /> t _ .... ... . . .. ----- r <br /> --� .. . Roc--------- <br /> Size : �"� PropLined•---. ""( . <br /> -- -- -- Four) a n -- - ` <br /> Distance to nearest: Well-'.----.__ Fau - <br /> - fd� fia <br /> ! <br /> - -- --- t r <br /> • � ` 1 . <br /> REPAIR/ADDITION (Prev.. <br /> 'Date <br /> ' r - <br /> 5eptic Tank S ecif Re u•irements]-_-_ - =- �' <br /> r = -- ---------- --------------------- ---------- <br /> Disposal Field.(Specify Requirements)_-___.. �`--------- ----=-------- <br /> 1 - --------------- ---------- <br /> --- ------ ---- - _ <br /> __ NX - �' _ <br /> ------- -------------- <br /> 'required <br /> ------- <br /> I (br`aw zisting and'requiired ad`ditioon on-reverse eves•e side] <br /> I hereby certify that I have prepared this application tsnd that-the work will be done in accordance with San Joaquin County <br /> Ordinances,: State Laws, and Rules .andil Regulili ons-of t_he a JoaquinfLocdl_Health District. Home owner or licensed agents <br /> signature certifies the following:ri <br /> q� t <br /> "I certify that in the performance of the`wo; for which this permit'is,issued;.1 shall not employ any person in such manner as <br /> to become subject to Workman's Compensatiionlaws of California' R <br /> Signed--------By - h _ 5�= = Owner <br /> = T itle _ <br /> - <br /> ._ <br /> s <br /> Fat -- <br /> h owner) t� ] <br /> f FOR DEP TMENT USE ONLY <br /> t <br /> APPLICATION ACCEPTED BY_ - w -----=-----------------DATE --=------- ------ ------- <br /> DIVISION OF LAND NUMBER - Y <br /> ------------- ----- <br /> ------- - -------- ----------DATE.---•--•--- - <br /> -- <br /> --- <br /> ADDITIONAL COMMENTS-- --- e- ra ~P�"s'P ° "'--- 1;-- = <br /> l - -------------------------- --------------------- --- - ----------------------------------------------- <br /> --------------- <br /> ---------------- <br /> -- -- - ------------------------------ ------ ------- <br /> ---------- - _ <br /> ` - ----- '� o t , ,� <br /> ----------- ------------------------------ �� <br /> Final Ins ection �b ,w��1:__,.�.---- � --�=----- -----=--= a e. --- ---� --Zas 21677----- ---- ---� <br /> r <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT REV. 7176 3 <br />