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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> ---------------------------- ----------------- --------- Permit No in Triplicate) <br /> '", <br /> - <br /> Date Issued--------------------- <br /> ------------------------------------------------------- This Permi#vExpir�esbear F'rom,Date Issued S <br /> '1„ �� ,✓ u yy \ adv i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This applicationiiis made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J ��-/ --- `-? -- -----.-�-'___CENSUS TRACT..___ <br /> JOB ADDRlSS/.LOCATION-... ;-�- / :���---- �-------: f --------------- ' <br /> Owner's Name- <br /> — ! Phone ---------- <br /> city <br /> i <br /> _. � <br />' Address- ---- -----�-----= e - �tY - Zip <br /> .. e !�_ -Rhane.� �--- I. --- <br /> C <br /> Confiractor's Name -•---L• <br /> ice�is -# <br /> Installation will serve: Residence [p�partment House ❑ Commercial El Trailer Court E] <br /> . . ..Motel•F1Other -=_. ._ . --. M r j <br /> I . <br /> Number.of living units:_-' ------Nu ber of eplrooms---- Garbage Grin a Lot Size �Q._ .: -- D- _ _ <br /> F e •;�+� <br /> Wa#er Supply: Public System and Warne - ! 'G+ - --------- Private ❑ <br /> Character of soil to a depth-'of 3 feet: Sand [] It❑I"Clay. Peat.0 Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ A , Fill'-7ti7Lateri•dl-.r± l_If yes, type-------------------------------- <br /> dobe <br /> 4 [Plot plan, showing,size of/lot, location of, system in relation to`w-eifs;builcvir_lings�etc-must-be placid=ow reverse side. ' <br /> NEW INSTALLATION: %,(No:septic `tank,or seepage pit permitted if public sew s is ava ab'le,w thin 200 feet,) i J <br /> r <br /> PACKAGE TREATMENT [j' SEPTIC TANK [ ] " Size------------ ---------------------------------------Liquid Depth.-------------------- -� <br /> ` .. Ca acf.Y Type _ Matevial ` No. Compartments.-' ------------------- <br /> P-Yly------ YP - <br /> r i [[ <br /> Dista .to nearest: Well-------------------- .-' ---------- Foundation- Prop. Line I - <br /> LEACHING LINE [_] . No, of Lines --- :.Length of each Lina _------ _ _-----:total.Length -_ --- _______ . _-_... C <br /> D' Box Type Filter Material ., ._Dep h'Filter-.Material------------- - ;. -.:----- .___ <br /> ;.. .- 1 - <br /> tl r i f <br /> F. <br /> FF :Distance to nearest: Well---------------....... ... .Foundation -`____._-.Property Lin"e-�--._ ....... <br /> i SEEPAGE PIT [ ] Depth __ ...Diameter _____________Number_-- ----------------------- r Rock Filled Yes.Ll No <br /> t <br /> Water Table Depth-----------------:-------------=-- - Rock Size <br /> Foundation '-- --- ---------Prop. Line------------------------- <br /> t REPAIR/ADDITION {Prey. Sanity ion Permit#.._.-.--- _...____ -_...=.._I- - i. <br /> Distance to nearest: Wel].............._... --------- _---- <br /> - Date_}.---- �- --- ------------------1 <br /> Septic Tank (Specify Requireme f. `` '` -E ---------------------- <br /> ---------------- - <br /> - _ ,- <br /> . ¢Disposal Field (Specify_Requirements)---- " �- r' '^`� --- -----` <br /> E ---- --- <br /> ----- --- - - " �- - --------------- --- � <br /> l �. ' -- --------------------- <br /> ------------------------ <br /> ----------------- - <br /> r !t------- ---------------=--- ----- --- --------------- ------------------------------------------------------_ ----- -- <br /> r <br /> 1 - � (Draw existing and required addition on reverse side) 3 t <br /> J T I hereby certify'rhat [_have.prepared.tlhis�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 /> iignature certifies the following: t <br /> "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannerkas <br /> to become subject to Workman'sCompensation S-0 f Cq_l.ifornia." _ <br /> t <br /> ;-:--- `-- J s - _ ----.Title--- � -------------------------- <br /> _ -------- ---BY Owner---� - <br /> (If <br /> t <br /> other than owner) . <br /> FOR DEPARTMENT SE Y <br /> APPLICATION ACCEPTED BY-------.........__-'-_-_---_-:---..........-----'-- -------- <br /> == DATE c`�-�J'I Z-- ' <br /> DIVISION OF LAND NUMBER.--------- ---- -- ----- ---------------- ------ --------------- DATE. <br /> ADDITIONALCOMMENTS----------------- -------.------------------- -------- ------- __------------------------- ---------------------- :--- <br /> - <br /> - -------------------------------------- ------ -- -------- ---------------------------------------------------. <br /> ----- ---------- <br /> ---------- <br /> - -p c - - - - ---------- ------ --- - .. -= ---=_--- ----------- —...�. Yf� ----------------- <br /> EH <br /> - -- - <br /> Finai Inspection-by-.----- - - ----------------------- -----Date:------ �� - �- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH L dac`�, <br /> TF`& REV. 7/76 3 <br /> t <br />