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FOR OFFICE USE: a. <br /> s ------ -_- At- .CATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> _----------------------- (Complete in Triplicate) Permi# No.-__Z�_,Y <br /> •- ------ - This Permit Expires 1 Year Front Date issued Date lssued_..`-�--- = <br /> ication is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein de <br /> application is made in compliance with County Ordinance No. S49 and existing Rules and Regulations: scribed. <br /> ADDRESS/LOCATION---- lv- <br /> ---•- -._ <br /> s Name - CENSUS TRACT <br /> ------------•---••----------------- <br /> 1-�`� ? one-------- = <br /> I`� U <br /> -------------- <br /> Ph <br /> - Ci <br /> ty <br /> ----- - -------- iP-- <br /> eactor's Name-------- <br /> -••---- <br /> ��-�'�' �—�o <br /> Rationwillserve: - .._ - - --- -------•---_----Phone-------------__-• ...... <br /> Residence Apartment -----•----- ..License #--Mouse <br /> ❑ Com ercial❑ Trailer Court ❑ <br /> Motel C] Other._ _ <br /> ber of living units: /--------Number of bedrooms__..__ <br /> Garbo a Grinder--------- <br /> -Lot Size-------_--_ <br /> :�PPIy: Public System and name---- -------- -- <br /> ------------------ <br /> 3Cter of soil to a depth of 3 feet: Sand❑ Silt❑ ClayPrivate ❑ <br /> Hardpan ❑ Peat❑ Sandy Loom ❑ Clay Loam <br /> #� ❑ Adobe❑ Fill Material_----------_!f yes,type-------------------- - <br /> plan, showing size of lot, location of system in relation to wells, buildings,etc.must be placed on reverse side. f <br /> :INSTALLATION: (No septic tank or see age I t <br /> 9 Pit permittedy1f -vbl'z_seln►�r.is..av9iloble wi#hin 200 feet,) U <br /> :AGE TREATMENT f } SEPTIC TANK [ <br /> SiSize_ 'F - ,�' d` <br /> --�_....X �-----------=--Liquid Depth.---- <br /> Capacity-- AQP-------Type- ------- ` <br /> �-�t Pte -Material---- --- ------ No_ Compartments__.. ,_ <br /> .._ : s <br /> Distance to nearest: Well...........:p" ___ . ----- ---- - <br /> - ---- Foundation.- ----- <br /> RING LINE - - - t Prop. Line._.�' <br /> [, No. of Lines-------_ _ /-•------ <br /> �-- �------•---:__-_--Length of each line.....--�'`-.�:- <br /> -- -------•-:-----Total 6ength.------�� � <br /> 'D' Box-—____Type - --- .----------------•---- <br /> ype Filter Material s-- --.Depth Filter Material___------ <br /> •�" <br /> Distance to nearest:Well_-.__-. Q_1___ <br /> :Foundation= -�k- :_ <br /> _----.Pro e. Line-__.._..5___________________ <br /> lGE PIT { De th_ S` <br /> -Property <br /> Diameter. Number.--•-------- <br /> Rock Filled Yes No <br /> Water Table Depth------ <br /> -- -- ------ <br /> -bC - �� ❑ <br /> -------- - <br /> Rock Size_-- <br /> v <br /> Distance to nearest: Well -------- <br /> - -______________ O a <br /> ._.._Foundation-__---- -� _`---:__-- . <br /> IR/ADDITION (Prev--.'Sanitation Permit,#--------------------- h <br /> Pro Line__. <br /> ---- ----------------------Date.----------------- --- ---------------­ <br /> -------------------------T6nk[Specify Regyirements}.._.--------•-- �--} <br /> ----- . - <br /> Isal Field S ` <br /> ( pecify Requirements}----- ------•----------------- <br /> ------------ <br /> _........_-------------------_------_------__ --------------.-----------------.__. - <br /> (Draw existing and required addition on reverse side) <br /> by'cerhfy that.I have prepared this application and that the work will be done in -t.tccar lance with San Joaquin County <br /> ai lies, State Lawsi and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> lure-certifies the following: <br /> hfy that in the performance of the work for which this permit is issued, 1 <br /> cine subject to WorJcrnan's Compensation Jaws of Cafifarnichaff nota.'• ereiploy any person in such manneras <br /> .... - -------------- ---•---•-- <br /> .. ------------Ov✓ <br /> Owner <br /> ------------ - <br /> - --.Title_-_--- - _ -- - <br /> (If other than owner} <br /> FOR DEPARTMENT USE ONLY <br /> CATION ACCEPTED BY.._ --- <br /> ----------------------------------- <br /> [DN OF LAND NUMBER. DATE._... �'"h `.r---- - --------- <br /> - -- -- <br /> IONAL COMMENTS---------------- -------- -------- ------- ---•--------------------- -------------DATE:----= = = = <br /> r ••----------------------=....... ........... <br /> -•---------- --------- ---------------------------- --- ----------•---------•- --------------------------------------- ------------ ------ ---------° -------------- <br /> 7----------- <br /> -----•--------=------------------ <br /> r- <br /> Inspection by:_._- -: f--- <br /> ----------------­------------Date---- _ <br /> SAN .10AQ IN LOCAL HEALTH DISTRICTv <br /> F&S 21677 REV. rues 3M <br />