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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- <br /> {Complete in Triplicate} Permit No._-;7?'_- pyo <br /> --------------------------------------------------------- <br /> ---� Date Issued_/a <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby madW 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 existing Rules a d Regulations. _ e. <br /> JOB ADDRESS/L TION /_ - - F-- - ------- -------- `_-----"- -.---- <br /> CENSUS RACT------------------------------- <br /> Owner's Name--- - 7-� -- -- ..... ------- <br /> -------------Phone _. '© <br /> Address- -- ----- ---- - '' - City -------------- <br /> --- <br /> - ---� .Z-iP ! <br /> Contractor's Name [ ! License # � - ____--f'Isorie--------------------- <br /> Installation <br /> - -- --- t <br /> Installationjwi11 sea,ve: Residence ApartmentiHo se ❑ Commercial ❑Trailer Court ❑ <br /> ' 1 r i ,`, Motel.. ,. Other..T-,- » ---- -- --- <br /> u <br /> �bedroorris--��tiGarbage Grinder = = Lot Size ---- ------------------- ---------------------�, <br /> Number of livingunits.-_�_ -__ �-____ Number of y# � _ � <br /> Water Supply• Public System ands rr a=- -� = == "' T ----- ---------Private <br /> .. {� j r 1 <br /> Character of soi! to a depth o{3 feet: �SbncJ ❑ Silt❑ Clay El ,� Peat❑ Sandy Loam ❑ Clay Loam <br /> ...,...-.�.* f <br /> 4 � '. - Hardpan Ado"':�e�Q,r rill Material__...:_.__._If yes, type________________________ _ , <br /> (Plot plan, showing size-6f-1 t Bloc aw of'-"system i'ri relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: "(No septic tank or seepage :pit permit#ed if public sewer is available within 200 feet) <br /> PACKAGE,TREATMENT 5EP71`C'7ANKSize_ __"_______________________________:-------------- Liquid Depth------------------------ , <br /> { Capacity '= _'-_ TYP, = Notarial- --------------------'._No.-Compartments------------------------- <br /> r t <br /> aDistanceao nedrest: We!!_.. .--"----------------------------Foundation--------------------------Prop. Line----------------------- <br /> NE �- <br /> LEACHING LI [ ] No. of Lines.__,-- F _M l <br /> -- „ <br /> t <br /> � ., gth of each line.------.. �-_- - _ ------.Tota! Length----------------- -�---- _ <br /> D' Box.------- -_T a Filter Material'-------------------Depth Filter Material--------------------------------------,---------- --------°---. <br /> Distance,to nearest: Well--------- -------------------Foundation----------------- ------'---Property Line---------------- -----------.--� <br /> SEEPAGE PIT [ ] j Depth--------------------Diameter_ .................Number----------:----------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table"; ... 4 <br /> Depth-- ------ - -- ------------ --- Rock Size <br /> DiOcince jo.nearest:We11 ----`"--- -----------�--------------Foundation----------------------------Prop. Line---------------.------------- <br /> REPAIR/ADDITION <br /> -----x---.REPAIR/ADDITION (Prev. Sanitation Per it#-------- --------- �! <br /> ----------- ---------------Date.--- `- ------------------------ - <br /> Septic Tank-(Speci#y-Requirements)_— .-- --- ----- ---- '- - �=` <br /> �r rr <br /> _41411. � � , <br /> Disposal Field (Specify Requirements);,.-- - ---- ce-4.6"ate----X- c_ _ <br /> k -------------'----------------- <br /> ---� ----- --- ----- - _ ----------------------------------------•-----------------------------------"<-----------------------------------`--- <br /> (Draw existingand required addition on reverse side]- <br /> 1 hereby certify that.1 have prepared 'this-application and-that-the work- will be­done-•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 p orrriance of the"work foi whichthis­permit is issued, 1 shall not employ any person in such manner as <br /> to become �$,object to orkman's Co ensati laws of California." ... <br /> F fW <br /> ned �+t; ! s sK H'' - ------- <br /> Sig <br /> -`---,------- ----- ------'- ----- -----------•----- <br /> 8Y Title- ----------- -- <br /> (I_f otRer•`tfian owner) <br /> - FOR DEPARTMENT USE ONLY' <br /> APPLICATION ACCEPTED 8Y- = ----------------- ------------------------------------ ----------DATE. X77-=---- -------- <br /> DIVISION <br /> ---DIVISION OF LAND NUMBER--------------------------------------:---:--------------------------- --------------------w------------------DATE-------------------------------------- ---ADDITIONAL COMMENTS------- -- -------------------------------- <br /> ------------------.----- ----------------------------------- --------------------------=-------------------------------------------------- ---- I <br /> -- ---------- --------- ---------------------------- ---- ------------- -------------------------- ---- ----------------------------------- <br /> 7 <br /> ------------------------•- ------------- --------------•- ------ ------------------------- - --------------- -- ------------------•---------------- <br /> ------ ---------------•-----•-------- -------------- - ------------------- ------ -- -------------------- <br /> Final Inspection-by:--------- ----- ------- --- ------ ---- -_ ----= ==--- ---Date--_--- <br /> EH is 2a SAN JOAQl1EN LOCAL- ALTH DISTRICT F&S 21677 REV..;-7/76 3M } <br />