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FOR OFFICE USE: <br /> - APPLICATION FOR SANITATION PERF` T <br /> - "-------- -------------------- Permit Nermo.7 <br /> (Complete in Triplicate) Z=_ --- ,� <br /> ---- ----=------------------••-••----------------------- <br /> Date Issued _ _.:3 <br /> -- . ----�-L' <br /> ___-----------------------•----------- -, This Permit Expires 1 Year From Date Issued <br /> Application,i�»hereby•made to the, an oaquin.Local Health Distr'- „ori a per�it_ o con trus�tt,and i s all the work herein <br /> described,.,Vis appliccition is made <br /> in <br /> ml3liatice ce No35 and 'xi�tAgl.k�l s nd Regulations: <br /> JOB ADDRESS/LOCATION �`-- - --------- -------T;Mp-----CENSUS TRACT -------------------------- <br /> Owner's <br /> ---._-.------.---__ ._ <br /> Owner's Name _M-__ _�--_ P.ho_ne .. <br /> ff <br /> Q_ 7 .Q....... <br /> Address ----- city ---------c <br /> Contractor's Name --------License --_ Phone46i l ..7... <br /> Installation will serve: Residence ❑Apartment House❑ Commercial❑Trailer Cour <br /> Motel ❑Other --------------- --------------------- <br /> - a <br /> Number of livin units <br /> g -__ Number of bedrooms .3--- Grinder _NQ_�_ Lot Size _/4C_ A.6 _ - <br /> Water Supply: Public System and name -------- -------- --------•-----------------------;--------------------- , •-----•---- -------Private <br /> Character of soil to a depth of 3 feet.' SarTc' -.Silt ] ICOay [] Peat❑ Sand�.Loam -❑_CI21Loam,[] <br /> J40rdpan ❑ Adobe"o Fill Material ------------ If yes,type----------------_-..-__--_- <br /> (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings,..etc., must.be.plctced on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) C <br /> PACKAGE TREATMENT ( ] SEPTIC TAN.-V`e Size . Z_ --------r1_1 14ci id .Depth - Irl__•.____...- <br /> aterilCapacity __0_0------ Type O MaNo. Compartments r'11 ..r:.... <br /> Distance to nearest: Well .-__...._.._:----------------------Fo i dation :- ---------------- Prop. Line _3 00..•...... ' <br /> LEACHING LINE No. of Lines --__ Length of each line--------- ------------------ Total Len th 9_24e. <br /> Len g •----•--•-- <br /> Ltt �� <br /> D' Box -Cl.)--. Type Filter Material IA-1 S-.Depth Filter Material I---F........................____._.____ <br /> r `` <br /> Distance to nearest. Well /60-------------- Foundation c�_6. ----------- Property Line.-4700._-___-:.... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ' ------- <br /> --`--------------- t <br /> . -------------------------------- <br /> Disfiance to nearest: We ------------------------ --------1-------Founda ion -------•---. Prop. Line .............. ------- <br /> : <br /> +, <br /> mDate ----- ----••---•------------------ <br /> IREPAIR/ADDITION(Prev. Sanitation Peri it <br /> ts]Septic Tank (Specify Requiremen ----=----= ` --- <br /> - ------ -------= ---------------------­ <br /> Disposal Field (Specify Requireme --------------------'------ ' ------.-- - ----•- � ------•--------•-------------- -----•------------•--•----------- <br /> iI <br /> -------= <br /> ---------------------------------------•--------------------- ---------------------------------------- ------ ---------- ----------------------------- --------------------- <br /> ------------------------------------------------------------- <br /> (D,avw•e -stirag.atad�requ ---- -itif n on reverseside) i <br /> I a <br /> .I hereby certify that I have prepared this application and tha he iNrork will I done-in accordance with San Joaquin �{ <br /> County Ordinances, State Laws, and Rules and Regulations o the Sc e J irr"�ocal Health District. Home owner or licen- <br /> sed agents signature certifies the following- <br /> "I certify tha the performance pf.the„ar. k for�yvhich t is permit is,issued, I shall not employ any person in such manner i <br /> 'k as to beco su Iect tqW man's�Compensation laws of California." <br /> Siecl 6----------;- --- - -----FOwner <br /> --------- - ------------ <br /> i <br /> BY ---=--- - --------- -- <br /> i <br /> e than owner) ► L" .. <br /> I, FOi .DEPAiRT�RENT LISE ONLY <br /> : - --- DATE: ----------------------------------- <br /> ADDITIONAL <br /> ff 7 <br /> � iAPPLICATION ACCEPTED �Y�-----� --•-: ------------=�------------- ------------------------------------- DATE �.-.�.F- __.------------ <br /> BUILDING PERMIT ISSUED -------------------------- -----------------------------D -- - <br /> ADDITIONAL COMMENTS ------------------------------------ <br /> - -Y-- - �-- <br /> ---------------------------------- ---- ------------ ------ ----- -i----------- ----.. ----------------- - - --.-...------------------------------------------- <br /> -- ---- <br /> ,. - -- --=--------------------=-- . . j <br /> 'nal Inspection by: -_�12T -°1< ---------------t---•-•-------- HEALTH DISTRICT----- a e - -- <br /> -_Date <br /> -�. ..SAN JOP&6UIN L8CAL HEAL r_-- <br /> H- 9 1-'6$ Rev. 5M <br />