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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION--FOR,SANITATION PERMIT <br /> --- Permit No. ---- ----- --- <br /> (Complete in Triplicate) <br /> ------------- Date Issued- 70C <br /> _-- ------ This Permit Expires 1 Year from Date Issued r <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. Rules and Regulations:- <br /> , <br /> " T N <br /> JOB ADDRESS/LOCATION-- ! [[' = ---.CE SUS TRACT <br /> Owner's Name rJ--Y-O� ------------ ---------------- ---------Phone _ <br /> Address.. r �� d� SMSA �..I P-- ------ ------------ - Cit Ci41 t] Zip �f - <br /> y - n1.n�c Y- _ <br /> Contractor's Name__ ' -- cS7..Zl Phone_X3(0 `3.3----- - <br /> -•-------- <br /> __.License <br /> Installation will serve: Residence ❑ Apartment House❑ Commerci9l ❑ Trailer Court ❑ <br /> w ,. �. .. .. <br /> Motel ❑ Other---=- , <br /> r `l•�.._.�...Z--, ,----''�E-,�----------------------- <br /> Number of living units:---- -_.--Number of bedrooms-.- Garbe. e.Grinder..____.__ Size.__-.- I -_----- <br /> •- '-------- ,g -f-- _--�- �.°----- -- -� ..i � ---------- ----Private � <br /> Water Supply: Public System.and`name ___-----_._ ---------------- i <br /> C <br /> Character of soil to a depth of 3 feet: Sand Silt Clay Peat Sand Loam Cla Loam <br /> p ❑ ❑ Y'❑ r 0 Y I � Y ! ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material- ' - If yes, type-------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to vi-ells,.�buildtngs'etc.-must-tie placed on reae�rsee side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avoilableswithin 200 febtAV <br /> PACKAGE TREATMENT [ ] - SEPTIC TANK` <br /> Size--- -` -----��'�---- ��4-[ i Liquid ;Depth.-- /.- <br /> n ---------- ------ <br /> Capacity—/-2 A$T e"K " 1Naterial._: C_.•---No. Compartments _ <br /> ------ <br /> Q ! .. Foundation---1 Prop. Line--- I ---------, <br /> Distance.to nearest: Weil-_.�- ------ ------------------- <br /> I <br /> ki -. , <br /> -- Total#FL'engthk <br /> M <br /> LEACHING LINE ['� No. of Lines_ � en9thof each line -- 7-� -- ------------ D p' Box_ � __Type Filter Material-]—- -04'--Depth Filter Material ....I r Distance to nearest: Well____�_��-�-'�------- --Foundation____: _.��_ _______________i=Property•?L•ine-- _--------------------- <br /> LA- - <br />! `© � i ; Rock Filled Yes No <br /> IT [I Depth--f----------- �- pf Number <br /> Water Table Depth--•---------- <br /> ---r---- ------- ------------- <br /> ------------ <br /> -Rock 5iz� t-- <br /> O _- Prop.to nearest: Well---Z-0-g! ---------Foundation____ ._:rE---_____-__. p- <br /> �� <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------- -------. ate------ j----------- ) <br /> i <br /> Septic Tank (Specify Requirements)-------------------=-----i----------------------------- . <br /> Disposal Field (Specify Requirements)-----------------=------------ -----------=------------------------------------- <br /> - <br /> ------------------------ <br /> t <br /> -- -------------- <br /> --------------------------------------- --- ------------------------------------ -------- ------------------------ ------ <br /> (Draw existing and required addition-on reverse side) <br /> . I hereby terrify 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: <br /> "I certify that in the performarice of the work for which this permit is issued, I shall not employ any person in such manner as <br /> "to become subject to Workan's Compensation laws of California." <br /> 1 ----Owner <br /> 'Signed---------- --- - ------ ------ --- --- ---- ------�=_------- ------------ <br /> Title--A --- { , <br /> i 'BY-` <br /> L-:_ ----------- - <br /> {lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> III I <br /> DATE ------------------------- <br /> J <br /> - 4 -- ------------- <br /> APPLICATION ACCEPTED BY-----•-� --------- AL - -------------------------- ------------------- <br /> ---- ------ <br /> ,•DIVISION OF LAND NUMBER--------- -------------- - DATE. <br /> a ADDITIONAL COMMENTS-==---- ----------= ------- --- ----------------------------- <br /> ------- '--------------------------- --------------------- ------------------- -------- -------------------------- -------- <br /> ----- ---------- <br /> j E <br /> ----------------- ----------------------------------------------------------------------------------- <br /> ii eH . = <br /> ---------------------✓----------------------------------------------------------------- <br /> ----------- <br /> Dat <br /> e <br /> -Final Inspection' b <br /> F' <br /> Fes 21671 REV. 7l76 aM <br /> +3 24 SAN JOAQUIN LOCAL HEA <br />