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-if ;i, l -ter- .•...-. <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> - o�, . <br /> ---------------------------------------- - APPLICATION FOR SANITATION PERMIT Permit Nol--/."_33_-y" A <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- Date Issue <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.insta11 the wjK herein ej_described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: t <br /> JOB ADDRESS/LOCATION---4,0 !dwZaA� <br /> ." CENSUS TRACT . _- <br /> 1� / ---Phone-- �� c -- <br /> Owner's Name._Y `e_v'�'?-Q--�'1 --' --=��f?_l�C,��j"{-'=--------------------------- --•---- --- -------- <br /> � <br /> Address" -_ '�' " _: - ----- ------------- ----..---._i City-..-- -------------- ----------------------Zip---------------- ---- ------- <br /> Contractor's Name----- ----------*------------------------ --'_License #----------- -------------- -Phone------------ ---------- ---------- <br /> Commercial Court <br /> Installation will serve: Residence ❑ Apartment House.[] Commercial ❑ ❑ <br /> Motel ❑ ,d Other------:LT- :---------------- <br /> Number of living units:__._/--------Number of bedroom s_".-_Garbage Grinde•r------------_Lot'Size------_ "�_" _.-------------------------- ---- <br /> 4 ----_":Private,. <br /> Water Supply: Public System and name---------- : _ '� = _'- :-., <br /> Character of soil to a depth feet` Adobe SlFill Material--Ej ❑ Peat Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ ❑ h = ----If,yes, type---=------` ---------------- <br /> � y <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is availab i 0rDepth.__Z/F1__ <br /> Size." i -------- <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [.] - -- ----- ---- -- ---� <br /> ' e _ Material_-� _`4:f&__No. Compartments__ <br /> Capacity-/ 0.0 YP / = y <br /> �Distarice,to-neare : Well:;,..!-_�J_d. Foundation,/10— ---_--Prop. Line_-- <br /> _._ <br /> LEACHING LINE No. of.Lines_.: _ ,_.Length of.each ling.__ ."""____,_"___Total Len <br /> th ___, _, ---------"----:---- <br /> 4 I <br /> D' Box _----Type Falter Material' -"_�"h._'Depth Filter Material f -, --" ---------------------------- <br /> ----- <br /> _"-" __ <br /> $ Distar}ca to nearest: Well":_ �------------------Foundation._"" __µ / ' <br /> _ = Property Line"-: <br /> SEEPAGE PIT [ ] Depth ---------------Diameter------- ------:----Number------------------------------- Rock Filled Yes No = <br /> Water Table tDepth---_ -/---- - Rock Size-------'---------------------------------------- <br /> Distance <br /> ---------------------------------- --Distance to nearest: ell - -------------- -----------Foundation---------------- ------.Prop. Line--------------- --------t-- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-:g__-""_--------------- _Date----- ---------------------------------------- <br /> Septic <br /> ---"--------------------------------Septic Tank(Specif;Requi�ments)-----------------•°-:- ------------ ---------=- ---- - -- <br /> ----------------- I---------'------------- ------------ ------------------------------ - <br /> Disposal Field (Specify Requirements)------- ----- ----- - -------------------------------------------.------------------------ . <br /> _ <br /> --------- <br /> --- ------------------------- --- <br /> •fi <br /> ----------- ------------ ----- ------------ ----- - <br /> - ------------ <br /> (Dr <br /> - •� <br /> (Draw a isfng and required addition on reverse side) <br /> I hereby certify that I have-prepared this ppplication <br /> 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 /> signature certifies the following: <br /> "I certify'that in the performance of the work for which this permit is issued, 'l shall not employ any person in such manner as <br /> to become su iect to Workm ColyipZrigption laws of California." <br /> :. <br /> Signed---- - -- --------- Owner. <br /> Title ------------- - ----------- -- <br /> BY-=---------- - --- <br /> (If other than owner) <br /> FO EPARTMENT USE ONLY f <br /> ra APPLICATION ACCEPTED BY:'- � ------------------------------------------------------ DATE.- 3� <br /> t <br /> DIVISION OF LAND NUMBER'-------- ---------------------- --------DATE----------------- ----------------------------- <br /> ✓ ADDITIONAL COMMENTS- '---------------- ----- -------------- = <br /> ----------------------------------------- <br /> -- <br /> -----=--- <br /> --- ! ------- ------- ------------------------------------------------------------------------------------- ----- ------------ <br /> ------------- <br /> '< - <br /> Final Inspection b - Date <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7176 3M <br />