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} - FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit 7-$ <br /> ---------------- (Complete in Triplicate) <br /> ------------- <br /> -- Date Issued-_�`-fes-`- <br /> R <br /> --------------------- <br /> --------- This Permit Expires 1 Year From Date Issued I <br /> ------------------------------- <br /> ermit to construct and in <br /> the work herein describe <br /> d. <br /> 71�- tyct <br /> Application is hereby made to thNonce wi h Countyuin Local <br /> OrdinancneSN6, 549 and existing Rules and Regulations- <br /> Thi 5 <br /> egulationThis application is.made in comp CENSUS TRACT- <br /> ---------------------------- <br /> ,—- ..-- ----------------- r� <br /> r s <br /> {. <br /> JOB ADDRESS/LOCATION..- '!_ �;< Phone -._ �� = <br /> - - - --- -- - <br /> -- ---- <br /> Owner's <br /> .Owner's Name--------------- , . . s - -- � -- - - -_�- - -- �- SU <br /> .. T --- .'City­ <br /> � / ------ <br /> " o <br /> 141-f-- -'!. - } " --- - Phone_ - <br /> Address � License <br /> 4. <br /> Contractor's Name_,-------- ----- ` * Commercial ❑ Trailer Court ❑ <br /> ' Residences° Apartment House Q <br /> t installation will serve: r --- ---- -------- - --- ------- - <br /> t Motel ❑ Other �. ----------- <br /> Size-. - . - - <br /> l �'Garba e Grinder. :-Lot.- at <br /> Number of.living unitgs:�- �( N.u.mber o..f bedroo_rns - -'��.--g <br /> - . <br /> t Private <br /> ❑ <br /> l Public;System and•name -. - -: Peat <br /> Water Supply.. " Sandy Loam ❑ Clay Loam [I <br /> haracter of soil to o depth of 3 feet: E <br /> Sand ,-1�5;(t Y >Clay ❑ ❑ <br /> Adobe Fil.l_Matial------------If yes, type- ( �.�- y <br /> ( Hardpan ❑ - r r a <br /> s 4 — buildings, etc- <br /> (PI <br /> be.placed on re�erse side.) V <br /> w -. - <br /> (Plot plan, showing size of ldt, location of system in gelation to wells, <br /> 'tan'k or seepage pit permitted if�public sewer is available within 200 feet,) (q� <br /> NEW INSTALLATION' - 'i(No septiic t F. r -^-^'"^---- ciqusd Depth-------------------------- <br /> SEPTIC TANK' [.]� Size----'-------------------- ---- ----- ----- -•-- ---- - <br /> PACKAGE TREATMENT '[ ] Matsrial--------------- =--No. Co p m s------------------------------- <br /> --- <br /> ----------------- - ----- - <br /> --- - m art enc -- - � - <br /> Type------------=- <br /> . _.. Cap dcsty..--_�.- ='::--- m <br /> ` I , Foundation--------=--------- -- Prop. L` e <br /> . ..... ._... Distance to nearest: Well•------- ------------- _�_ --! Total. Length. , <br /> i = <br /> I ` . -. -- --�- -- -.Length of each lane -:.-- - - ( <br /> LEACHING LINE �o• 0f Lines-.-,: - _ -_ - -- -- - -- --- - - - <br /> - v•ye-Ftlter-Mater-jal-�- Tou dation.slt i p ,, + € <br /> - 1 Pr - ty L ne --- <br /> Filter Material. '' .- <br /> D .Bon = <br /> - F t .- . r <br /> Property <br /> ., { (' <br /> ( ] Dista to nearest: Well - - 1 Fsl Yes❑ No❑ <br /> De th . --- --- = -Diameter .- -- <br /> ,�_.. . . . Number--------------------------------- <br /> be <br /> - -- - --� --: 4 <br /> Rock I <br /> .. € _ _ <br /> SEEPAGE PIS L 1 p -----Rock' Ssze <br /> I t - <br /> .. . � : .. Line ----------- <br /> rWater Table'Depth.--:- i a } 4 <br /> ,L "_`.�`Zearest: Well -. - - <br /> Foundation � = Prop. <br /> Distance t4 SZ t - - . ate. <br /> D <br /> cws : - .,._� l f <br /> # t 11 ' <br /> REPAIR/ADDITION {Preva Sanstao Permit;#_-"--- -- - y1g <br /> k Septic Tank (Specify Requirements)`- !11 t r -- -- - -- --- -- -- -- -- -- - - ----------------------------------- <br /> sl <br /> -- -- -- - -- -- - -- - --,- <br /> --- - <br /> Disposal Field (Specify Requirements)------ -- � ! "" 3 <br /> 5' <br /> ��r : <br /> I <br /> I <br /> -- <br /> - - --- <br /> - �. �: ----------------- i y <br /> '` ,d addition.on reverse side} , <br /> +. (Draw exist1 9 and require ��1 e� <br /> application and that the work will be done in-accordance with San Joaquin County <br /> I hereby certify that:l have prepared this app €.- <br /> rdinances, State Laws; and sRules:and Regulations of the San_,Joaquin Local Health District. Home owner or licensed agents <br /> O ! : t <br /> signature certifies the following: i erson in such manner as <br /> [—,-signature <br /> • "I certify that in the peiforman a of the work for which this permit is issued, l shall of emp oy any p� <br /> . i <br /> to become.subject.to Workmanrs .Compensation..laws of California." <br /> Ownesir <br /> t ` ' - - ------------- <br /> ---------- <br /> - , <br /> ---- ;� <br /> Signd__. _ : - -- --- : <br /> 3 - - .. t; <br /> -------- -------------- <br /> - <br /> -------- :Title--- <br /> --- - - - f <br /> _r ------- ,T <br /> - i <br /> By- ------- OR <br /> -- I other than ownerl _ <br /> 1 ' PARTME T USE ONLY ' <br /> - --- ----DATE.:. ----� - - -- <br /> - ---=---------- <br /> - = -' -.------ <br /> NUMBER <br /> --- = <br /> DATE. <br /> APPLICATION ACCEPTED BY-----'.�--- ---� ----- ----• �-- ----� ----- --- I <br /> ------- <br /> DIVISION OF LAND NUMBER--- : : ------------ - - -- __ : <br /> t '� ------- = <br /> ADDITIONAL COMMENTS------ ---- ` <br /> - - -- -- - - _ - ---------------------- ------- -------•----------- - <br /> --------- <br /> --------- <br /> G_�►- � ' °�-- "ti''`' ' "`` ---------- -------- : <br /> Dot J�a <br /> - e --- <br /> __ -- . <br /> - —`- <br /> --------------------------- - f&S 21677 REV. 7/76 <br /> Y, <br /> Final-Inspection b -- L- - <br /> SAN JOAQUIN LOCAL HEALTH_DISTRICT <br /> EH 13 24 °� <br />