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FOR OFFICE USE: FOR OFFICE USE: <br /> -� APPLICATION FOR SANITATION PERMIT <br /> ....._.____._..._ 79 337 <br /> -- - - -- - (Complete in Triplicate) Permit No.____....'_..__... <br /> Date Issued$.-/.� .. _. <br /> ._...__._.._......_.._......_...._......-.-.__ This Permit Expires 1 Year From Date Issued <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application is made in compliance <br /> pwith County Ordinance No.549 and existing Rules and Regulations: //JJ <br /> B ADDRESS/LOC N_ - lQ✓.1.�._.._ (��_�_�..�..�..__._� CENSUS TRACT..O .G t!/t� <br /> ner's Nome....,t�/JIt_�--�KJ! --------------------.._. -------------- -....._ - - one------_.�t`2 .�0J`" <br /> Address------- .- --------C---t-------000 -- -- ----------- -- City..-. . ._r.--------------F------Zip--------=-..._..._.--...... <br /> Jonirador's Name__ __ h. ._._..._.__..License #� .`�^.7 .._Phone_ <br /> installation will serve: Residence E;, Apartment House❑ Commercial ❑ Trailer Court ❑ <br /> . Motel ❑ Other..-------------------- --------- ............. <br /> i <br /> umber of living units:....._.-___Number of bedrooms..,.3.....Garbage Grinder------------Lot Size_ <�'�.-�Z_ _'..___.............._- <br /> Water Supply: Public System and name.---------------------- ---------.--- ---------- -----------------------------------__----------------------------------------Privc te,Q' <br /> aracter of soil to a depth of 3 feet: Sand ❑ Silt p Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Er� <br /> Hard$an ❑ Adobe❑ Fill Material------------If yes,type................................ <br /> lot plan, showing size of lot, location of system in relation to wells, buildings,etc. must be placed on reverse side.( <br /> INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> I <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [sj� Size.__-_ti?._.XS//i�X_ � ��J._..__Liquid Depth.... <br /> PACKAGE <br /> Capacity_/Zwcr _-._.Type.-(_ .. ___----____MaTerial._..[A.0 --'--___No. Compartments----- ??.---.-.....--..._... <br /> 4 Distance to'neargst: Well- --.__.__..__.___-_.-----Foundation._.-Z-P _._._..Prop. Line�aQ � <br /> LEACHING LINE W No. of Lines----- Length of each line--------y©__.__.......Total Length__.f ._.....-._____._..._ <br /> 'D' Box./�~Type Filter Material./,Xi��Depth Filter Material._..ra.._1_.._.._____._.._-__._ -__._--------------_.C <br /> Distance to.nearest:-Well__! O_ �..___Foundation_._��__S--------- -Property Line_.. ./------ <br /> .._.... 6 <br /> /r � <br /> EPAGE PIT (•]� Deprh��2 -..._Diameter._36_..-------Number...._._..._._.______...- Rock Filled Yes4 No ❑ <br /> Water Table Depth-----/ f------------�.,..= ------------Rock Size._ -----X I-`-�------------------ <br /> - - .-..--- --• <br /> Distance to nearest: Well___ .-'�r.._S_.-------_----------------Foundation_r-S. /.____Prop. Line <br /> PAIR/ADDITION (Prev. Sanitation Permit#-----------:.:_...__._.._._--_------------=....Date---------------------------- -.-----------) <br /> -Septic Tank (Specify Requirements).... ------ ---\--------------------------------------------------------------------- -------- ------------ <br /> Field (Specify Requirements)----- ------------------ -------- <br /> --------------------- <br /> --------------------------------_.-------------------- ------------------------------------------------------ ......`-------------------- ----- ----------------.---------- ------- <br /> _...............-----------...-------...------------ ---------------I--------------- -------------------- <br /> -_ (Dcav(,existing and required addition on reverse side) <br /> lereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> nature certifies the following: <br /> 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 subject to Workm n's Compensation laws of California." <br /> Jgned............ ...- A----- '---- - -- ----- - - Owner <br /> y _..... _.. 4�C - Title- & w <br /> . ._---------------------------------- -- ------- - --- --- -------------- <br /> (If other than owner( <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.'r - --- QZ� f---------.._------- --- -.--DATEDIVISION OF OF LAND NUMBER_--------------------------_f------------------------------------ ------------------------- --------DATE----- ----- -------------------------- <br /> JDDITIONAL COMMENTS..------ ...... ----- ------------ ---------------------------------- <br /> - ---------------- - <br /> --- - <br /> - <br /> -------------------­------- <br /> --------------- -- ---- - ---- - -------- ---- ,9----------- <br /> nal <br /> .. . <br /> nal Inspection b :-�- -� --------------- -------------------- --- - - - - --------...- - -- - -- - - -Dater- --------------------_------- <br /> A --- - <br />