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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT p <br /> ------------------- - --------------------- 71 .3 <br /> (Complete in Triplicate) Permit No.... ... ..... ....... <br /> ------------------------- - ------ -------------- <br /> -------------------------------------------- <br /> ------------- ' <br /> Date Issued... �� <br /> ....._______,___-..._------------------------------ -- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health',Di`strict for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 r •_ _ ------------ <br /> --- <br /> .- " ------------ --- --- CENSUS.TRACT----------..-------------JOB ADDRESS/LOCATION.-- � '--=-=-ti :._----- rJ ,.`, <br /> Owner's Name _ Phone. <br /> �� H <br /> . :_... s.t Cit Zi <br /> Address.------ ` ° Y p <br /> -------- <br /> Contractor's Name >°'- --- <br /> Installation <br /> ! _:A,./ �-� !:._ ='/i_i,License #c; -c7 71"7 ZPhone�_f- ----.: ! <br /> " Apartment <br /> 0 ❑ " "- --rcial ❑ Trailer Court ❑ 1 ( ► <br /> Installation will serve: � Residence MotelA art0tn�eHouse - Commercial <br /> e <br /> Number of living units: .Number of bedrooms..- .Garbe a Grinder 7 Lot Size_.- F. ..--------- ----------- <br /> Water <br /> - ._Water Supply: Public System_and name ----------------------------------- ---------Private ❑ <br /> Character of soil to a depth of 3--feet: •Sand 0-5ilt❑ Clav O —Re'at❑-.. -Sandyaoam ❑ Clay Loam.❑ <br /> Hardpan ❑ Adobe" ,a Fill Material"-k _.-.--If yes, type- --- -- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �> 4 <br /> NEW INSTALLATION:.—(No septie tank.or seepage .pit permitted�if public sewer is available within 200 feet,) l <br /> PACKAGE TREATMENT [ ] ' SEPTIC.TANK I:] ]Size '--------------------`------------`-- -----y---;_Liquid Depth ` <br /> � D Capacity,.---�"--=r---� " - �pr � '---------.� Foundation -_--=---�------- -----Pro . Line_ <br /> T e Materia .No. Compartments- --_ Cj <br /> Ii <br /> Distance-L.to nearest: We ----------------------------- .. _ �_..� -----------i------ ------- <br /> ---------- � <br /> LEACHING LINE. No.,,of Lines . :- . :.,- _Length of each line -__3S Total Length. - t <br /> C <br /> t .. ` Type.Filter NlateYial {� ---Depth Filter Material-/--X - <br /> e <br /> d�^ fes✓ <br /> _ ndation..... __.Property Line-.-- <br /> DistancElto ne est Well - Fou <br /> SEEPAGE PIT Depths - Diameter _f Number } <br /> �'_4_ # _ Rock_Fillbdi Yes No ❑ <br /> .-�..�.- —.water'Table Depth ' --------------- '"` Rock Size - ---------------, <br /> �. <br /> r, Distance.to nearest;Well.. .0----- _---------Fourclation._"Za---tn---- -- Prop. Line-___ -- -- ..... <br /> REPAIR ADDITION (Prey:Sanitation Permit#. ------ ------------------= --_------- ---------Date--------=-------- --------------------- <br /> 1 , t <br /> Septic Tank (Specify Requirements),- ;_ .-. :- j !-- r� �g .3 , <br /> Disposal Field (Specify Requirements)------G�_" <br /> { <br /> ��..a� __ <br /> ---- - -- / <br /> (Draw existing and required addition on rever'see side! <br /> hereby .certify,that,1,have prepared this application and that the work will be done in accordancetwith San Joaquin County <br /> Ordinances,: State Laws, and Rules and Regulations of the, Sari Joaquin Lccal'Heaith District. Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in "the` performance of the work for which this permit is­issued, I shall.7hot employ any person in such manner as <br /> to;become subject to Workman's Compensation laws of Cahfo a " <br /> t Signed. - .'.. --- ----ecce-- -Clwner LAR£ S PTfF C & SEWER' SERVICE <br /> C <br /> .i .�.r..G. � .� - 263 So, Oro u Stockton, Calif: 95205 : <br /> --- _ -1___ '-T r ---- ----.-Title- --------Fh:4 _ # <br /> By-: - --- . ` f 1 <br /> 3209 r✓ohi.ractor'S Ltc:-#26X77 e <br /> (If -other then o er) - <br /> i t " FOR-DEPARTMENT SE ONLY t 1 <br /> APPLICATION ACCEPTED` BY ---------------- ---------------- -- - ---- --- - ---:DATE <br /> DIVISION OF LAND NUMBER--------------- = DATE: <br /> -------------- ' <br /> ADDITIO L COMMENTS------G>PYYW - . ""°-R -D_' `'et "-'-`- - °�"'''1 <br /> �_ = ----- . ---- --------- -------------- <br /> ----------- r� �_� 7g - <br /> ------ ----- -- ----- ---------------- ---- ------ ----- <br /> ------------------------- - -- = - - -- --------------------------------------- ----------.---------------------------- ---- - ` <br /> Final-Inspection by." - _..R_.,------ -.-Date.----- --- -------- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV-7176 3M <br />