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r '`FOR OFFICE USE: ; <br /> r FOR OFFICE USE: S�3 <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No.- - <br /> ---------------- ------------------------------ -------"- (Complete in Triplicate) <br /> 1 tet. t <br /> Date Issued--- <br /> ---------------- <br /> This Permit Expires 1 Year from Date Issued <br /> Application' is hereby made to the San Joaquin Local Heanth,DisNot for <br /> a permit to con <br /> and exist ng Rultes and Regulations:ruct and install the work herein described, <br /> - . <br /> This application is made in compliance with <br /> County Ord A !! <br /> ----- <br /> 5? i ;._CENSUS C� + <br /> JOB ADDRESS/LOCATION ,- " : .__- ::. ,:_----- __ $ -------------------- ,' TR .. <br /> I U <br /> �k ------------------- <br /> :- - phone. <br /> . <br /> Owner's Name._ G <br /> O -Zip ---- -- <br /> c <br /> . �}}!�. <br /> Address-- -- -- =-- - - - - -�- i--- --- ----,-- . .__ -�: <br /> + � C+ty t <br /> -- Lice nse#- <br /> • 3 <br /> Contractor s Name-:----- ..-- <br /> t "" . ._ - A artment House ❑ Commercial ❑ Trailer Court ❑ <br /> l serve <br /> R <br /> In <br /> -,will • <br /> Residence r <br /> .. . -- <br /> ote! �❑ Othe <br /> G L �A -------- -------- --- <br /> rindea.-- -_ i <br /> ` Garbage -. <br /> Number ofIiving.units---._1.-=- Nurriber.of.bedr..00ms_:._. _Private <br /> I ° ' ` _ - - <br /> 'l . Public System and`name__ :. '- - .- <br /> - -- <br /> Water Supp y San L a ❑ <br /> . <br /> t ' Peat ❑ <br /> Sandy oa �] Clay_LO m <br /> Character of soil to a depth of 3 feet: i Sand [] iSilt ❑ `.Clay ❑ F ... ...,., r. . _ <br /> Hardpan ❑ ` Adobe �+ Fill at- 3e If yes, type -- • <br /> _ i r <br /> (PI ot plan, showing size of lot, location of system in relation to'wells, buildings, etc.�muvaable withced On 200 feet}h reverse +de) l� <br /> l NEW INSTALLATIONC (No' TAN or seepage .fit permitted if public sewer is a <br /> p <br /> K [•� Size_ - -..---- <br /> SEPTIC - ' --Liquid Depth----- - ---------- ---� <br /> PACKAGE TREATMENT <br /> [ l `, Y <br /> /boa T e ry 'Material = '-No: Compartments --------- --------------- <br /> P,. Capacity::. C -----_ yp, ! i = �i7 !, <br /> ' r f Foundation - _._Prop. Line_ 7� <br /> - Distance.to neare'st:.Well-;-� -_ � ' <br /> 4 f -.-------- <br /> LEACHING <br /> Total Length 4--=---------- ---------------------- <br /> ------- € v <br /> LEACHING LINE:,-. ['l. No..ofLength of each line___ -- �g <br /> + <br /> � - r - h Filter Materia <br /> a _O. <br /> + -0-,- <br /> ---------- --- - <br /> D' Box-- '- Type Filter Mater+al :-----Dept <br /> . . ...... r S - <br /> Distance to nearest: Well------ �d_ --- foundation-_ --'------- -Property Line_- ------- <br /> Filled'+l <br /> ler) Yes E] No� <br /> €' SEEPAGE PIT [. ) Depth--^--`--- ' --Diameter '.-- ---------:----Number <br /> iz <br /> ---- -- <br /> Rock ,I -e---------------------------- <br /> - <br /> i + W <br /> Distance to nearest: Well. ', `-- - -- Prop. Line ill <br /> Water Table Dept � - -•---- ---- <br /> -------------- <br /> --------------- - L- <br /> { F i <br /> Date -- _ <br /> _ _ oun atian.__ <br /> REPAIR/ADDITION (Prev. Sanitation Permit <br /> ;. <br /> :. ----------- <br /> ------- --- <br /> s ---------- ------------ - <br /> ----- --=-------------=---- ------ <br /> ------------- <br /> Septic Tank.(Speci#y Requirements)------------ ; <br /> f Disposal Field. (Specify,Requirements)-:---------- - _ <br /> } <br /> ----------------- <br /> __ __ <br /> __________ t t <br /> .__--__--.__---__-.__ <br /> Draw existing and required'additionion reverse side) i t <br /> ( : ; <br /> I hereby certify that I have prepared this application and that the 'work will be-done in accordance with San Joaquin County <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: T i <br /> f <br /> "I certify that'in"the performance of the work for'which this ,per•init is issued,--:I'-shrill 'not employ any person in such manner as <br /> to become subject to Workman's--Compensation laws of California.'.' <br /> Signed__ v T�o ._s - -- - - ---- <br /> a�!/' :Own <br /> -------- <br /> Byr------------------------ <br /> - <br /> itle -�' .-�• y <br /> , �• ' _ .: • - �; .. <br /> OR DEPARTMENT USE NLY <br /> DATE,---.:- `` <br /> �- --------- <br /> DATE..--.:- <br /> 11;00 <br /> �'' <br /> - -- - ----- - <br /> P.PPLICATION ACCEPTED BY --- ------ ------ - --- DATE.:-----.------ ------- ------.------ <br /> - . .. i1 4 <br /> DIVISION OF LAND NUMBER------- ------ ---- .......... - -----------._- --------------------- - ----- <br /> ' --- ---------------- <br /> ADDITIONAL <br /> -- ---- ----- <br /> ADDITIONAL COMMENTS------------------------ =: =__. 4' <br /> i ; ' -------- -- .- ------------- ------------------------------------- <br /> ------------- <br /> ------------- - --- _------ -------- <br /> ------------ <br /> ------- --- - ----------- - - <br /> r <br /> ,. <br /> 1 ----------------------• •------------- - Dat <br /> ---------------- - - <br /> W�L <br /> Final.lnspectionoby:_= __ Fa 21677 REV. I 3M <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fly - <br />