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FOR OFFICE USE: FOR OFFICE.USE: ;
<br /> APPLICATION FOR SANITATION PERMIT A0/
<br /> - _ ------ - (Complete in Triplicate) it "
<br /> •�/ Dote Issued./ . .......7
<br /> __._....._.............................................. This Permit Expires 1 Year'F��ram Date Issued
<br /> Application is hereby made to the San Joaquin Local Health District fdr°nermit to construct and install the work herein described.
<br /> This pp p Countyexisting_ _ d Regulations:
<br /> T- r` _ ,. _
<br /> Own is Name...... ... ------ .,.......::: , ---.CENSUS TRA -' -----..
<br /> aT�7_ . .
<br /> JOB ADDRESS/LOCATIO !n-com7���_�un Ordinance o. an u es_ao - --^-- Phone... ._:.. ..;.
<br /> r
<br /> Address..--=---- ----'-1sr.) ..._._:.._. -- -:� --i C�. -- . --' _ ...._ .------Zip•.:.` ---
<br /> Contractor's Name-...,,2.1f1... ,li�Q ....��.�.L.O'-------------- '...._. nse �#.�O.S7 ----Phone--- ----- ----- - -------
<br /> ..Lice, QP '33
<br /> _.� P .-
<br /> Inftallation,will serve: Residence Q'�A Apartment House Q Corrimercial Q Trailer Court Q
<br /> t
<br /> _. :. Motel p Other...::_. -------- .. .... -
<br /> Number of living units: .,_ -. .....Number of bedrooms:-:5. -Garbage.Gcitt1er ' - Lot.Size...... ..... . .:._ _�...{v`
<br /> Water Supply: Public System and name - ' �' - - --- ... .s... .'-. Private,�y
<br /> Character of soli to a depth of 3 feet:1 Sand b !Silt❑ Clay❑ : Peat' Sandy Loam ❑ Clay Loam 8�
<br /> • - _
<br /> Hardpari-❑ Adobe❑�. Fill Material_ . _ ._If yes,- e---.------ ._..__.... ------ ,
<br /> (Plot plan, showing size of lot, location of system in relation to wells, builcl'i�gs,letc. must be placed of reverse side.)
<br /> NEW INSTALLATION: (No septic tank or seepage 'pit permitted if public sewer is available within 200 feet,) -
<br /> PACKAGE TREATMENT [']' ' SEPTIC TANK ____-:.._ !.".---� _.-- ...�_-'_.I_ Liquid Depth.:......:.....,.......:..
<br /> � . . .. .Capacity-='-`- -.....TYIx- '-`-` `---:r.:.Material-- ------------------ No: Compartments-'-
<br /> { _ Distance lo.nearest: Well.:_,. ..._.. oundat]on.,::...:.......h::.::_.Prop. Line.,_:...;:.__.------ ..
<br /> I .i v t t
<br /> LEACHING LINE [ ,] „No,..of,Lines.-----;:.:....:.....:.._,_.tengthofeach line...._.__,,,,_:_,,..,_:...,..Total,Length........;---------y;------E..........
<br /> i 1D' Box-,____....Type Filter Material: ----,__._..----Depth Filter Material.__,____� _
<br /> _. .I........
<br /> ... _______________........ ._.
<br /> I i .Distanceto,nehrest: Well i} .�� undatlon_, - I
<br /> -------------- Property Line-,----- - -------- -- ---------
<br /> SEEPAGE PIT ...Number _ ._ I Ro[k Filled Y"01 No
<br /> iWater Table DepTf1----------------------- ....:.:.----�-----�----..,.�..Rack Size:------i------:----•-------:------------------- r
<br /> Distance-to nearest: Well_.._............ ...i......'............-.:F640 elation----- --------....:..Prop.Line.................... ._.--•
<br /> REPAIR/ADDITION (Prev. Sanitation Permit#...... . .................. .____,._.........[;D e__..._..... .—'t 1 ,
<br /> i Septic Tank (Specify'Requirements)---=- .......... .. .............. .. .
<br /> ..._
<br /> Yi.
<br /> Disposal field (Specify Requirementsl.......: .....0 -.'4�r e.-- •- 7----`--- -------------�` -..-- --
<br /> r .f ,S (!t ° I t
<br /> ....................................... ...----..-------------------.-------------------.................. --............... ---- ------------- - -- t ........
<br /> --------------- ----------------------- .......................=--•-••--_._..--......-- _. ........ .---. .....—�a......... ..' -- ..... -- - - — ----- ---- V---------
<br /> "(Diav✓existing and required addition r on reverse side)
<br /> 1 hereby certify that'l have prepared this application and that-fhe-work-wilkbe^done In accordance_with -San �Joaquirikounty,
<br /> Ordinances, State Laws, and Rules and Regulations of ithe San Joaquin Local Health District. Home owner or licensed agents
<br /> signature certifies the following: - �- - '• j
<br /> "I certify that in the performoncaofflie work for which this permit is issued, 1•shall not employ any person in such manner as
<br /> ' to become subjec YVEon's Compensation- laws ofCalifornia.”Signed - - - . .. r ...... . ............
<br /> I
<br /> By. ....
<br /> - 4 \Title. -
<br /> - If other than owner) , '�J FOR DEPARTMENTUSEONL•Yi___s
<br /> APPLICATION ACCEPTED BY e_ - .-.� -- -- -'. ........DAT�.f ../�—y; 7�... ..
<br /> DIVISION OF LAND NUMBER... .. ____ - .. _,., r _DATE�( ,.
<br /> -j�K^r-----------------
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<br /> ADDITIONAL COMMENTS-----....__....... -------------•------•----.........-------.-----------..-------------- - � -
<br /> . . - •. ..- ----------- ....
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<br /> -----:.__...._-____....._..._-----------------------------................_......__:-___.._..__.._...._...;.;,:_,_._...._............ Ty 1.........
<br /> _____ __________________ _ _____ __ _.�.___ . _ _ _ ____._-__-_ _ _ -. -
<br /> Final•Ins Inspection by:...:......
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<br /> FH 13 24 SAN JOAQfUlN LOCAL HEALTH DISTRICT Fes 21477 sfv, 7/24 2M
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