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FOR OFFICE USE: )-30 FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 7,�- <br /> '------- -------------- Permit No.------ --------------- <br /> . r c ,(Complete Triplicate)------- '` ----------------- L� a .` <br /> ~ Date Issued._�_�-3_... <br /> �I----------------------------___..._...___._. This Permit Expires I Year From Date Issued <br /> i <br /> Applicll tion 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 349 and existing Rules and Regulations: x <br /> CGI^ e - CENSUS TRACT------- ---- <br /> JOB ADDRESS/.LOCATION.._.'/. :--... ------------- <br /> Phone <br /> i T - ---�--- ---- <br /> JOB <br /> Name_:_� 9 -''. ` ----. - - Phone , <br /> ». <br /> Address -- f --G`` { C tY <br /> II F ---- -- -- - Phone--- <br /> Cont <br /> ractor's Name-- --. -... --- -------------'------- -----=------- <br /> License # ��1�3p <br /> Installation will serve. Y Residence [Apartment House ❑ Commercial E] Trailer Court E] + <br /> v-:- <br /> --- Garba e Grinder ---Lot Size__ - - ----- .--- <br /> Number of living units:._._ /3 Number_of bedrooms, i <br /> .II. <br /> / , <br /> Water.Supply: Public System and name----------- --------- _-- L-- - - . - Private"❑ <br /> Character of soil to a depth of 3„feet: Sand 0 Silt❑' C!'y'� Peat ❑ Sandy Loam ❑ Clay Loam ❑ w <br /> Hardpan ❑ ' AdobeFill Material__1_ "!'f yes, type <br /> --- ----- -----i <br /> (Plot plan, showing size of lot, location of system in relation to.wells, buildings,'etc, must be'placed on reverse side.) *\ <br /> NEW IIINSTAELATION: (No;sepfic tank or seepage pit permitted if public sewer is available within 200 feet,) { <br /> . . . --- Liquid Depth.'---.-------- <br /> ... <br /> PACKAGE TREATMENT '[ ] • SEPTIC TANK” [,] ' � <br /> Capacity ---- TYPe " Materia! a No. Compartments .r--- �' <br /> .. Distance to nearest: Well.= Foundation - _--------=- Prop. Line- <br /> LEACHING LINE' [ ] No. 'of,Lines ._. f '__Length of each Fine "_. _ Total Length --------- -._. <br /> x `D' Box Type Filter Material:-- -_ --Depth Filter Material-"__ <br /> a :,; .i.. r -- -- <br /> DIS '�... <br /> tante to riedest:-Well ----------- Foundation—- ' ___.Property Line ----__ --------------- <br /> SEEPAGE PIT [ ] Depth------------ __Diameter __ F .Number..__. __._,t - ------ Rack Filled Yes ❑ No E]i Water Table Depth.--`----------- `--- _-`--------.�- = Rock Size-------------------------------------------- ; <br /> f. Foundation--------- ----- ---.Pro Line-------------- ------ <br /> Distance to nearest: Well --- ------' ----------------- P. = <br /> REPAIR/ADDITION (Prev. Sanitation Permit#_.?._'-------------------=--- '----------- --Date-----° <br /> E `IjIr. <br /> =i <br /> ------i-----= ------------------- <br /> - <br /> --- <br /> ---------r- <br /> ----�------ <br /> -_ : ------------ = }� <br /> - -- ---- ---- <br /> --------- - <br /> SepticTank'(Specify Requirements)--- <br /> m' - -•------Disposal Field {Specify Require ents)_.__A�_ -------------------- --- ------ /�----------- <br /> r-- <br /> -- <br /> - <br /> l-------------- -------- ----------------"-'--------- - --- . , <br /> ------=------ ------------------ - ------------------ - - -.-------- --- -- <br /> ---- ------------------------------------ -------------- -------------------------------------------------------- <br /> (D <br /> ----- ----- -- -- - --- ---- ----- <br /> ---- <br /> (Dw existing acid requiebd addition on reverse side) <br /> I hereby certify that'll have prepared this application -and that iie,work will be-clone-in accordance with San Joaquin County <br /> Ordinances, Stare Laws; and Rules and Regulations ofjthe Saan"`Joaquin Local Health District. Home owner or licensed agents <br /> o <br /> signature certifies the following: ?t' <br /> I� <br /> "I certify that in the performance of the.work for which this permit is issued, 1 shall not employ ;any person in such manner as <br /> to become ject to ork 's Com erisation laws .of California." <br /> Signed--. --- p - . .---------------,----:_Owner <br /> ------------ ---- - <br /> � ----- ------= <br /> itle € <br /> other than owner) <br /> I- <br /> FOR-DEP ART NT-USE ONLY <br /> APPLICATION ACCEPTED ---- -- .--- - <br /> ------- ------------DATE.--- <br /> � �t�--- <br /> DIVISIONOF LAND NUMBER=--------------------------=-------- ---- -------- ------------------ --- ------ -- ----------------.DATE----------------------------------------------- <br /> ADDITIONAL <br /> -------------------_------ - --ADDITIONAL COMMENTS------ -- --------------------=----------------------------�--------'`- ---p- ---- •- ----------------- -------------------- ------------ <br /> I� - ------------- -------------------------------- ------------ <br /> I� --- -- ------- -- <br /> ----------------- <br /> - - --� ---�-------7 <br /> = - ` . <br /> Final,:Inspection b w :-- -��_ .,.. - Date. <br /> EH i9' F&5 21677 REV. 7f76 3M <br /> 2a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �I _ <br />