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i <br /> FOR OFFICE USE: <br /> FOR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> -------- ----- _�P <br /> (Complete in Triplicate) Permit No.__ 7-'�Z.S <br /> --------------- ------------------- ---------------- <br /> �, e . <br /> - � f" Date Issued_.6_��-'-�-�7 <br /> Y -•------------------- ------------------------_...___ _ This Permit ExpiresNI-Year,F_rom/Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a p�j it to construct and install the work herein described. E <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 3 � <br /> JOB ADDRESS/LOCATION------ 1 - .-- ---.--- .- ---- - ---------- -.-------___ -- --=-.CENSUS TRACT <br /> Owner's Name.- qe-------- -- --� - -= -------------------------------------------------------------- --------------Phone------- J <br /> �. . <br /> Address..---; �_ ' City----- -- -- Z1 <br /> ----- <br /> Contractor s Name- -,,F�� _ cam. ---- ------•-.-------:License #_ce�� �_---Phone---- �� r ✓ <br /> 1 <br /> Installation will serve: } Residence j Apartment House [ Commercial ❑ Trailer Court ❑ 1 <br /> Motel ❑ :Other------------- <br /> t <br /> Number of.living units -- Number of bedrooms jg f ' <br /> ----Garbo e Grinder ._,, _- ___Lot.Size.___.__:�ems' <br /> e ,nn � J . h <br /> Water Supply: Public Systeni nd name_:�"�_-[ _'. -•---------------------- - ------ -- ---.,-----------------------------Private,10 <br /> Character of soil to ci depth of-3 feet: '. Sand E] Silt Q Clay ❑ Peat 0 A Sandy Loam ❑ 'Clay Loam ❑ t <br /> Hardpa 0j Adobe[Fill Material_. If yes,,type------------------ <br /> [Plot plan, show}rig size of lot, to ation of,system in relation to wells, buildings.etc. must be placed on reverse side.] <br /> NEW INSTALLATION: ;(No;septic tank or seepage pit permitf'ed if public sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT -]--,-SEPTIC TANK" ['] Size------ ---------- - ---- ------liquid Depth-•------------`------ ---- � <br /> i. a ,- moi A <br /> ; Capacity. �= Type ___ ----- - - ----------------- <br /> D <br /> ------ - �---� <br /> ° { Ddtance.to nearest: Well-------- ------------------------- ---- __Foundation_ _______ _______Prop. Line__ <br /> LEACHING LINE.' [ ] d`oof Lines.'-- ------ ----_ -- -Length th of each line-"..__ .-F. i <br /> ----_ Total. Length <br /> DBox­s_, Type Filter Material-------------------- -.--___--6 <br /> - DeptK Filter Material . __ --- -_:_____. i <br /> r.. F <br /> Distance tofnearest: Well - ----------------------Foundation ---------- -_ ' Property Line------- <br /> SEEPAGE PIT ;[ ] Depth-------_r_ .---Dkiameter---------------- --Number-n-------------- --------------_____ _ Rock Filled Yes ❑ No ❑ <br /> i ' _ Size.:,- - <br /> t <br /> �, <br /> ----------------------------- <br /> Voter bleDepth -W _Distariceto"near ---------= oundatio -- - - -"-- . rop Line " <br /> REPAIR/ADDITON � <br /> ]Prev. Sdnitation Permit#_______________ _______.Date=__.__°_.__. `` ___,___] e 't <br /> Septic Tank (Specify Requirements) ------- :_ _ :_ <br /> bis osdl Field (Specify Rei uirements/ `� <br /> : <br /> ------------------- x: - <br /> --- <br /> ---------- <br /> ------ -- -- <br /> ---- --------------- --------:--- ----- _- <br /> E <br /> y P (� -application q"�have Draw existing and re uired addition-on-reverse side) <br /> hereby certify that'I � � • • <br /> pre ared this•a lication and that.the work will- be done -in accordance with San Joaquin County <br /> Ordinances, State laws,, and rRules and Regulations of.the..San Joaquin Local Health District, Home owner or licensed agents ' <br /> signature certifies the following: i <br /> N <br /> "I certify that in the perforrhance of the work foy whit-h This'permit is issued,'I shall not employ any person in suih manner as <br /> to become subject to orkma 's Compensation laws;'of California,".. _ <br /> q <br /> Signed-------- --- -- ------ -- ---- - --- -- -----------------------Owner <br /> - --------Title..... - <br /> (If other than :owner) ] <br /> 'FOR'DEPARtMENT USE ONLY <br /> APPLICATION ACCEPTED BY: _.- s: ------------ DATE. <br /> ------ <br /> DIVISI <br /> --- <br /> DIVISION OF LAND NUMBER.-----.-,-------------------- ----- ------------ ---- --------------- ------- ------=- --- DATE.------------------ i: <br /> ADDITIONALCOMMENTS -- ------= --------------------Z--------- ---------------------------- =----------------------------------------------------------- <br /> --------------- <br /> --------•----------------------- ------------"------------------- ------------------------- --- ------- --------------------- -------•--------•--------------------------- ---- <br /> ------------------------------------------- <br /> --------=------ --------------------=--------- ------------------------- ------ ----_---------- ---- ------------------------ --- ----------------------------------- <br /> - ------------------- <br /> -----e-----.------'--'---- ----------- -- -- -----------_. .-_----- -- -- ----- ' <br /> Final Inspect b - __Data.--_..--..`._ —_r <br /> P Y::. -' ----.� = <br /> ER 13 24 SA J QUIN LOCAL M ALTH DISTRICT ray 21577 REv. r <br />