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t- FOR OFFICE USE: � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------..----- Permit No._7.7- _ ... <br /> (Complete in Triplicate) -- <br /> ------------- ......................................-...- Date Issued.e4G--1.2.17-_77 <br /> .......................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describec <br /> chis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION�...�.y.2�C.<2G----- _...... c.u. --.... ............._............... <br /> � � ..........CEN US TRACT.............. <br /> ��('�� w, ner's Name------'- t/Sat t4, .. . . . .................................... .. ......'-- •.'----• ---5 Phone-----__......._..... . ._--- <br /> _•^ddress...............7rr7® 0..-.. / - City..- C%lmyz u...............Zip - -- ---- - - <br /> Coniractor's Name ....�G��! �_[�D.__fr' `'� - i ' ' ---..License # 3w� .QLE....Phone_.._.. - ......- - - <br /> Cnstallation will serve: Residence Apartment House{] Commercial ❑ Trailer Court ❑ <br /> .. Motel ❑ Other-------------------------------------------- <br /> umber of living units:........ ......Number of bedroom �...Garbage Grinder.-.---------Lot Size__.__.r� ------- --_ <br /> 1 <br /> Nater Supply: Public System and name........... -.................................................- Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam 27 <br /> r Hardpan ❑ Adobe ❑ Fill Material...........M yes,type_ ................. <br /> �41ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> VIEW <br /> INS <br /> TALLATIO <br /> N: (No septic tank oree septic tank oreeage pi} permitted if public sewer is available within 200 feet,) <br /> i NT ( ] SEPTIC TANK [ Sizea__Xir�--��---i <br /> .57... ------------_._.._-___..Liquid Depth...-:7 ..--.---------- <br /> - Capacity. -------.Type.�' :Material.z-4'X:Q:,.........Noy Compartments.... ....................... <br /> Distance to nearest: Well---------A -------------------Foundation.....A�......Prop. Line.......-5.,Ae........ <br /> REACHING LINE [� No. of Lines.......................Length of each line.........'�_.'_....__._-----..Total Length ___— ...._------........ <br /> r + <br /> 'D' Box--------....Type Filter Material-----�`/�-.....Depth•Filfdr'Material...... ............................................ <br /> r [ Distance to nearest: Well........_A4.'1-i'0 ---.Foundation.-...._/1�-------Property Line...... <br /> '—SEEPAGE PIT [ Depth..p-�.z-l�--Diameter......53. .-'..Number..._..-_-_..3.r-�� :___--.. � Rock Filled Yes No [ <br /> �. ...:- L it <br /> t �€ <br /> Water Table Depth --'-- ----rydP ... ................... .....Rock Size /�-..../ - -..._..--........... <br /> Distance to nearest: Well..........1L:E.'/.�-f...............Foundation__.____.iProp. Line.---6E->fl-__.._... <br /> REPAIR/ADDITION (Prev..Sonitation Permit#...................................................Date__-_-.__.-___--.--............... <br /> ...-_..:._.:.) <br /> tieptic Tank (Specify Requirements).........................:.................•-------------------------------- --....................-.........--- - . --------------- ---------- <br /> t <br /> `Disposal Field (Specify Requirements)...................... .................................-....................................•'-----.............................---------------. <br /> T$ <br /> - __ <br /> t - <br /> ------- -.. -..----- ..---...-'------- -------------- -------------- ............ <br /> {Draw existing and required addition on reverse side) <br /> r hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin Coun <br /> Drdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or.licensed agen <br /> signature certifies the following: <br /> -11 certify that in the performance of the work for which this permit is issued, I shall not employ, any person in sucmanner <br /> become subject to Workman's Compensation laws of California." <br /> ' Signed........ .................................... <br /> - �f..........Jf - . Owner <br /> ! y .-.. ..._-..Title.-:Ly!!IL � -- --------------- <br /> - ------------- <br /> j Z (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ;APPLICATION ACCEPTED BY.-_ __ _ DATE......... .�.e!� <br /> DIVISIONOF LAND NUMBER_.............•-'-....... - ----...........--...-......•-------'-- ..... ..................DATE---"- --.............-_.-.... -`-- <br /> ADDITIONAL COMMENTS-------------------- <br /> - ..-_................... ..'---------......-'------ -----------.._......--------------•-----..----.--•--------------------------------------------- <br /> --------------------- <br /> ......•... ............................. - - -' ----- --......-•--------'-- - ...............---- .._.........--- ........... ------ - --- ..............--...---- <br /> --------------- ----------------- <br /> ------ ------- <br /> -- . . <br /> mal Inspection by:- --- - 'C'-- --... -•- -• •----'- - -'-- - - - - --'- . . ................ <br /> - - • - Date...------ �:,_ -�i--'- --'; <br /> j F 01 13 24 SAN JOAQU LOCAL HEALTH DISTRICT trs 3'°" REV.'n6 <br />