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FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.__.7f-?'``-1 <br /> ----- --- (Complete in Triplicate) <br /> ---------------- �/ <br /> ---- ------ ---- <br /> Date Issued_._.-"-.- -�-- <br /> ------- <br /> This Permit Expires 1 Year From Date issued <br /> Application is hereby made to the San Joaquin Local, Healthi District for a permit to construct and install the work herein described. , <br /> PP with County Ordinance-No. 549 and exist ng Rules and Regulations: <br /> This application is made in compliance Bance= r <br /> - <br /> CENSUS TRACT <br /> Phone. <br /> JOB ADDRESS/LOCATION... <br /> _ -_---- <br /> Y_. _---••-------- ------------------ <br /> -----Owner's Name--- - �'f�j}. ,-TV'�'-_' . Thi --- ------ ZIP------- <br /> CitY _ <br /> Address_ 3 .r_.Q.Qp. -------- r . Phone <br /> f•- _-��-[��tl._._ -•---- �--- ---- ---- ----- License #-- - -- `..--- -- -- ----- <br /> Contractor shame.__'-- -- Commercial ❑ Tr iler Court ❑ <br /> Residence ❑ Apartment.House ❑ <br /> _ a <br /> i installation will serve: i a <br /> z + * 'r.1 Motel ❑ Other - ` - <br /> F . <br /> -t ` Lot-Size <br /> ----- ------- - --- ----� - �. <br /> Number of living units:.;-_- Number of bedrooms----L_:_.__Garbage Grinder <br /> Private ❑ <br /> PP tem and.name---------------------=-- Clay Loam <br /> Character of soil to a depth t ❑ ❑ y Peat Sandy Loam ❑ Y <br /> Water Supply, Public ys <br /> pth of 3 feet: � Sand Silt I Clay ❑ ❑ e----------------- -- ---------- <br /> ' "Hardpan El AdoFill Material_._____..-.lf es, type <br /> A Plot Ian, showing SkZE Of}IOt;Vocation of system in'reiation to wells, buildings, etc. must be placed on reverse side.) <br /> ( P i ermitted if public sewer is available within 200 feet,) <br /> NEW IN (No°septic tank `or seepage pit p t.- Liquid Depth.---------------------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-------------- ---------- <br /> - --------No. Compartments ---------------------------------- <br /> Capacity -,ta o_._--:Type-- --- ---------------- <br /> AMatarlal- <br /> Pro tine f ------------------- <br /> -----Foundation.- ---- --- - P <br /> { Distance,to nearest: Well__.-_._------------------------ X .�v 3 <br /> ► *� Aellirel_ Ive� Length of each line. Total Length_- <br /> LEACHING LINE I l No. of`LinesA------------------------- <br /> LEACHING ----------g ,•gip _ --------.-.-..J <br /> ___Depth Filter Material <br /> 'D'. Box ---I- Type Filter MnaVFounlation�" ----------------- <br /> nc .. . <br /> -i "'�""pt perty'Line-- - - - - r <br /> ,, -... :. =-.• `- 'Distance toearest: WeIV'_ _- __ d <br /> Rock Filled -Yes ❑ No ❑� <br /> SEEPAGE PIT [ l Depth-- :--- ----Diameter -------- ------Number- --- <br /> RockSize----------------------------------------------- <br /> Water <br /> -------------- ---------------------------- <br /> Water Table Depth----------------- ------------ `: Line <br /> Distance to nearest: Weil-------- -------- <br /> Founclation------------------- Prop. <br /> w l t ------.Date.------- <br /> REPAIR/ADDITION <br /> =- ) <br /> REPAIR/ADDITION (Prev. Sanitation Permit#----=------------ -_,----- <br /> 3 ._% . <br /> k. ------ - --- <br /> Septic Tank (Specify Requiremen Is ----------------- -------------------------------- <br /> Disposal Field {Specify Requirements)-.---------------- ------------------------- <br /> ---------------------------------- <br /> -__ <br /> _ _- -------------------- - ---- -------------------- -- ---------------------------- <br /> ---- ------------ - --.-.. <br /> ------------- <br /> - ---- ----- ------=- ..........* everse side) , <br /> --------- -------- - - <br /> � _ � (Draw existingand required addition on r <br /> ►�.I hereby certify That I have prepared this application and that the work will be done in -accordance with San Joaquin County <br /> Ordi antes, State Laws, and .Rules and -Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> sigr,Yature certifies the following: <br /> r <br /> p ori person in such manner as <br /> �`( certify that'in the performance of'the work for whish this permit is issued, t shrill not employ Y <br /> t;' to become subject to Workman's Compensation laws of California." <br /> Owner <br /> Signed._ ' ' <br /> ----- Title--------------- ------ ----- --------------------------------------------- <br /> By <br /> -- ----- ---- ----- ----- ----- ----- <br /> y `•� •- of er than owner) <br /> FOR DEPARTMENT US ONLY <br /> - I - <br /> --�- --DATE ---- -- ----� - --- - <br /> k APPLICATION ACCEPTED BY DATE---------------------------------------------- <br /> --------------- -- <br /> DIVISION OF LAND NUMB ------- .-�-�{--- --Air••----. - ------------- -------------------------------- ---------- ------------------ <br /> ADDITIONAL COMMENTS--------- �J .._.. <br /> -------- ------------------------- <br /> ----------------------------- - - --------------------------- ------------- <br /> -------------- _. - _. <br /> --------------- ----------- <br /> ----------------------------------- - - — ate ----- ----- ------ - -- ---- ----- ---- <br /> - ------ -- --- ------ -- F&5 21677 REV.7/76? <br /> Final Inspection b -- - - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br />