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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------- - 7 � <br /> (Complete in Triplicate) Permit No------------- - <br /> Date Issued_r1.7Z3------ <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 described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION.... ----------------------CENSUS TRACT------------- -..-._..__.....-. <br /> :-�t.Z��.-------� .�'.�--�Q:.............................. f' <br /> Owner's Name.-...... CLS'-...... r.:: - 1-y ...............................Phone--.7 <br /> Address----- 5*0-r.-e-------------------- -------- ............................ Ci tY--••---5�-,Azrvek.f-rn----- -- _-Z __Z .. <br /> Contractor's Name................. Phone.-.- <br /> -------- .License #--------------------- <br /> Installation will serve: ResidenceoQ Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> pp Motel ❑ Other---- ------ -------- ----------------------- <br /> Number of living units:.__._1:------Number of bedrooms....�....Garbage Grinder-rte-.-Lot Size------ tkn.. .. .........:................ . .. <br /> Water Supply: Public System and name.--- --I f= --------­­--- ---- --- ---------- ......................---------- .................. -------.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay.❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material_- If yes, type...........-02,2 -/-aunt <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 available within 200 feet) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size..---------- -----------------------------------------------Liquid Depth............................ <br /> Capacity. .. ........Type------- -Material .,,No. Compartments------------------------ -------- <br /> Distance to nearest: Well--------------------------------- ---Foundation-----.- -_ . .. --.--.Prop. Line.............-.------------.,p' <br /> LEACHING LINE [ ] No. of Lines -- --.- ......-- Length of each line----------- Total Length ------------------------ - <br /> 'D' Box------------Type Filter Material...----- ...--..Depth Filter Material---- ..-----------------------•-----------------.--------------C <br /> Distance to nearest: Well----------------------------Foundation-----------...--------------Property Line------------------------- ------.-.¢ <br /> SEEPAGE PIT [ ] Depth.............---Diameter-----------_--.......Number-------------------------------- Rock Filled Yes ❑ No ❑, <br /> Water Table Depth............................... <br /> . .....................Rock Size.- --- --.......................--------- - <br /> Distance to nearest: Well----------------......-........------------Foundation....------------.-_ _ Prop. Line.----- ................ <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....-.-4"4110W-71 -......-----------Date.......... ------.__-__---------] ; <br /> Septic Tank (Specify Requirements)_._.. ----------------------- .......... -r--.-..-..- = --------------- ------------ -•-- <br /> / / <br /> Disposal Field (Specify Requirements)----- ._._:,� A`-C{T_...--.��--yt-,� •---Gx/�_..��1�i/ ---+-Aw-w.Ile-1............. i <br /> r <br /> lV (D <br /> ----------------------...--- - •-- --- ------ --------------------- <br /> raw existing and required addition on reverse side) <br /> I hereby certify that I 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 /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to WorkmanCamnsation laws of California." <br /> Signed- .- .e�aye� G -- ` ........... <br /> ------- ...... <br /> - . ......Owner ; <br /> By........................................................ ------ ................. ........... ..,,--Title.... --------------------------------- ...... .......... <br /> i <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------_-------- -----------------DATE ....... 7r ------------- <br /> DIVISION OF LAND NUMBER---- ---- -------------------------------- - --------- --------- --------- ... --.DATE ---.....-- ------- ........... : ........ <br /> ADDITIONAL COMMENTS. •----- --------- -------• - -•---_---------------------_ ------------------------------------ -----r------ -- -----.. I <br /> i <br /> ---------------------------------- ....... <br /> - __ - - -- -- - - - <br /> . . . <br /> � ---- -_ <br /> Pi_ .. a ... ... ... ... ....Final-Inspection by: -------- ---------- ------ D <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 RE�3M <br />