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- FOR OFFICE USE: ^ ,. . _ . _ <br /> FOR-'OFFTCE tlSE:'� <br /> 34 , APPLICATION FOR,SANITATION PERMIT <br /> ...----•------ ------•--._....- �-�-- Permit <br /> --�- -�- (Complete in Triplicate) '----- I <br /> ..-----------. ------ - ......... s' -�� <br /> Date Lssued:...-----�-----•- # <br /> ......... --------------- ----...---- ----.- This Permit Expires 1 Year From Date Issueaf <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 Count Ordinance.No. 549 and existing Rules and Regulations: ., <br /> F/+l 0 , #+I L� <br /> JOB ADDRESS/LOCATION = :., T ""CENSUS TRACT-.-: :":17r�r-s.. <br /> Owner's Name.. Fo PP.i^N_o..... ... ...60* ... . -------{. -------------- .... ....................... <br />. Address- ---- I Z, - S.-i E i S -j <br /> +��..A..4-w_ �--t1 city ---. .... <br /> .-. . <br /> ,. <br /> Contractor's Name--....... .--..License #. _34X IX!' _Phone__..��,1�'4�G'L__`.... <br /> Installation will Vserve: Residence.❑ Apar-tment-A&use-❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other_ VFPLC ....... 41 <br /> Number of living units:_:. Number of bedrooms g r ------- <br /> Water <br /> ...:--- • - _ Garbage Grinder --Lot Size , .x. ��.'� -- _ � ......:......� I <br /> Water Supply: Public System and name`---------------- - <br /> -- ----- -- ----------------- -- - ------------------- - -- -------Private [ ' <br /> i, <br /> Character of soil to a depth of 3 feet: 'Sand EJSilt ❑ Clay ❑ Peat ❑ - Sandy Loam [] Clay Loam [� ' <br /> Hardpan ❑ Adobe ❑ Fill Material _ __ ....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.) <br /> NEW INSTALLATION: (No ptic tankjor'•seepage pit permitted if public sewer is available-within-200-feet,� `R <br /> . TANK <br /> . _ <br /> = - .e�. f <br /> PACKAGE TREATMENT [: ] SEPTIC TANK [&r Size --------- ---- --- ---- - Liquid Depth.....4..!)�i <br /> _. - <br /> Capacity.1240-----------Type._W1_-C -Mate-vial----CCN.G.._--- Nompartments <br /> DistanceWell <br /> :_:_...r. <br /> ; <br /> to neatest: Well--- 3;00- -- --- .._.____.Foundation..-- -d'Or.:....__....Prop. Line...._.�i.r.............. .. <br /> LEACHING LINE <br /> [ No. of Lines ..-- ------�.---------'L�ngth-of-each Tina.:--.....�+-1�- ---- ..'` Tota! Length - -------------------- <br /> , . � <br /> 'D' Box 1:k.)..... <br /> tT;ype Filter Material..5 APmak- Depth Filter Material, <br /> Distance to nearest: Well.---- .'"-.--- Foundation.--.-_..SO.f----- -.-.-Property Line--- ..................... <br /> SEEPAGE PI7 �• - Yes Fr No <br /> [ Depth..�,.�-._....D�ameter._--��_.. - --Number---.-- --- <br /> /- ------------ -- Rock Filled <br /> Water Taljle Depth.----------/0� <br /> - ,-- ......--------------------- Rock Size--------.................----------------------- <br /> Distance <br /> -----:.-. ------ ---- <br /> Distance <br /> j t <br /> to nearest: Well------ <br /> --------- ---------------------------Foundation--.-.-: --.--..,.Prop. Line..-------i .----- ...... <br /> REPAIR/ADDITION (Prev'., Sanitation Permit#__. --- .----- --- -_-----Daate_--.---.---•--------•.....:-------.------------ <br /> Septic <br /> . ....:Septic Tank (specify Requirements)-.... - --- - <br /> Disiiospl Field (Specify Requirements)....".__._--_- 3 ` <br /> -------------------•- --...-_.---------- <br /> .._..----- F - <br /> ----•. ...... . ......... .... ---- a - ... ................ ....... ------------ ----_ _ ......- . - <br /> . -----..... . .................... <br /> { 4 f <br /> [Draw existing and required addition on reverse side) <br /> I hereby certify that I have }prepared this application and that the workwill'be lone inaccordance with San Joaquin County <br /> Ordinances, State laws;t�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 performan a of the.work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's' Comps satinn laws of Calif ornia."F'. <br /> Signed---- ... ---.,.---.Owner. <br /> By------ '�. --10+....: ; - � — - -.... Title,._ .A$)-/./.l .4mw. .---------- . .............. .... i <br /> (If other than owner) <br /> f0f DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--.-.--- '�` --.-..DATE ...- - .._�. .-7-- - ----------- <br /> p <br /> DIVISION OF LAND NUMBER --- F. DATE - € <br /> ADDITIONAL COMMENTS... ..... r�L 2� K .._... �I ----------------- ...... 1 <br /> ---------•----------- -------------- --- --------------- <br /> - ---... .......... ----- - ---------------- ..._--_._.....--..._...... <br /> -------------------- --------------------- ........... ..... ------------- --------- --------------- -- <br /> _ _- .. r, i <br /> y- -- e .: e..- 7. .?.. ------- <br /> EN <br /> . <br /> ENna 2A nspeCTlOn b .......... � Dat F85 21677 REV. 7/76�M <br /> 13 SAN JOAQUIN LOCAL HEALTH.DISTRICT <br />