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L <br /> 1 - <br /> FOR OFFICE USE: <br /> a APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> 77 �Fj7 e, <br /> c (Complete in Triplicate) Permit No.. .. ..-. .. ....... <br /> �4 .....................- <br /> ' . Date <br /> is . ............... ... .......... <br /> This Permit Expires 1 Year From Date Issued <br /> Application is herehy made to the San Joaquin Local Health District for a permit to construct and install the work herein described.- <br /> This.applicrtion is made in compliance with County Ordinance No.549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.. I �`" /I r-c_l;/_4 <br /> 1 <br /> 1Cbvwner's Name..... ... CEN TRACT . ....... . ........ <br /> Phone...... ....... ................... <br /> • •Address"....... .......�??�/�... ..-.�... � <br /> .... ... .. r" <br /> _try. .. Zip- <br /> Contractor's Name--.. . cr..r ..( %�•:'�:. .� -- rF rt y L j - <br /> ,cense # Phone-,..... <br /> r <br /> Installation will,serve: Residence ff" Apartment House❑ CammtYcial ❑ Trailer Court ❑ <br /> © Other_.. . <br /> Motel > <br /> , <br /> -�� .............. <br /> Number of living units:.. -...�.......Number of bedrooms---)//._.Garbage Grinder........_ Lot Size ........ .. . <br /> Water Supply: Public System and name... ..... . .. . <br /> . . <br /> ❑ <br /> - �/ <br /> _ -...._..-.Private'(�F <br /> Character of soil to a depth of 3 feet: Sand EJ Silt❑ C'ay Cj Peat Sandy Locm A" Cloy Leam <br /> ` Hardpan [7 Adobe❑ rill Murerial. If es, <br /> Ytype..... ....... .................. , <br /> (Plot plan, showing size of lot' location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW,INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENTSEPTIC TANK [tl Size.lfr <br /> 7. / r Liquid Depth./,/, <br /> [ 1 1 ..r - ��...",I'-J ------ --- ------ <br /> Capacity��dr......-_-Type..�We`C L7,-_MatcuiaL,_rt'f�c�!......No. Compartments.._o. ........ <br /> Distance <br /> Distance to nearest: Well...... <br /> ................."Foundation..../.. -...--Prop. Line.!...?.5./,'r` .� v <br /> LEACHING LINE. [f/� No..of Lines- "-_.-. ....Length of each line..... Length <br /> : �"•.......... .....Total .-..L��G� ---•-----�r.i_. 43. <br />! I r 'D' Box.,.../.... Type Filter Material-- ......Depth Filter Material....". "�11 <br /> ------------ <br /> 1)i stance to nearest:Well /ll�Gf` ,,, Foundation.__.- p ��, <br /> T / .....-.Property line ...... . <br /> SEEPAGE PIT Ell Depth.. .Diamerer....��.T .....Number.. ... .......: ... Rock filled Yes No <br /> E <br /> Water Table Depth.....-......�.. /.......- " <br /> �/"` <br /> L Rock Sae ��2..~i��� <br /> 1' rf <br /> Distance to nearest: `Nell. ..., ."Prop, Line. fc <br /> IR/ADDITION (Prev. Sanitation Permit#'.... .......... Date............ <br /> -.... [ <br /> :. ,•, Septic Tank (Specify Requirements[............... '6 <br /> ;r ',• . -.........."_....... ..---- ....". <br /> Disposal Field (Specify Requirements)"................... . ..... „ - ..•......_..._...F.;.. + <br /> ."._-_._..."....._....-"............................. l <br /> ? r ................................. .... ..-"..-..-...--..... ...." <br /> ..... ..... .........".-. ."...-........ ..........................a (Draw existing and required addition on reverse side[ IT <br /> s <br /> -.I hereby certify that I have prepared this. application and that the work will be done in accordance with San Joaquin County <br /> e' Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> fy ."I certify that in the performance of the work for whic:i this permit is issued, I shall not employ p y an y person In'such manner'as <br /> to become subject to Workman's Compensation laws of California." �. <br /> x <br /> - Signed---- ............ - ............. %_ -Owner <br /> -, By.:_'............... ::.•.:. ._....".--...-.. -. Ff!!!itre? f..f�r_y .tr` �Title.. �<�3Cfi�tfr�`. '...... <br /> .... / <br /> - ----- - ----- .. a r <br /> (If other than owner) <br /> " FOR DEPARTMENT USE ONLY <br /> -------- -- - ----- - — <br /> i <br /> APPLICATION ACCEPTED EY..-..1. ..................... . ..... .............DATE.. . <br /> s --- 7 .7..... <br /> I <br /> DIVISION OF LAND NUMBER............... ff.. .. ......DATE. <br /> ADD1TiONAL COMMENTS...---... ..... .. .......... .................. <br /> ............................... <br /> ' ......... ..................................' -....-fes-....._.- <br /> • ... ..... ............. .. <br /> Final Inspection by:..............:.......... .... . . . / Date.... .....- <br /> EH 17 24 SAN JOAQUIN LOCAL H ALTH DISTRICT FLS 21677 REV.7!76 7M <br /> byN <br />