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i FOR OFFICE USE: <br /> FOR, OFFICE USE: k APPLICATION FOR SANITATION PERMIT <br /> - - - <br /> Permit No.7��-1�n-- <br /> ------------------------------ - -------- --------------- (Complete in Triplicate) <br /> 0 <br /> ------------- Date lssued�-S--�/9 <br /> -- <br /> This Permit Expires 1 Year From Date Issued <br /> Applicatiorn is hereby made to the San_J_oaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance withRCounty Ordinance No. 549 and existing Rules and Regulations- <br /> T i <br /> ---------------------- -- ---- <br /> ---- <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION .. ----J ------ ,i- <br /> Owner's Name. Phone-� --- ------ -- - <br /> 1 ..--------"- Ci a�G ---° ----- - ----Zip--------' : ' <br /> 06 -----��. � tY--�.- Phone._��-`�����. <br /> F..- . . r <br /> nse # <br /> Contractor's Name._-------------- -- •--=--' ----------" --- A--- <br /> jai House ------------- <br /> -------------- <br /> - <br /> --Commer <br /> Lit <br /> t i•_ . } <br /> Installation will serve: , Residence, p j ❑ tial ❑ Trailer Court.❑ <br /> tL <br /> j Motel , <br /> .� -" ._, ' - ' ZOther---------- -- ------- ' <br /> - <br /> ` ----------- <br /> Number of.bedroom � age Grinde ..;_- -----------=------' <br /> Number.of,livirlgun'ts:__ s --'---Gar --- -Private <br /> Water Supply: Public System and;narrie ' - - =------------- ----------- -- <br /> i <br /> Character of soil to a depth of 3 feet. :Sand ElSilt❑ Clay 0 ; Peat ❑ Sandy Loam [I clay Loam 1v <br /> Hprdpan ❑ `Adobe`❑ Fill Material_,.._-..-If yes, type..--------_�:----------=- --•-- <br /> T <br /> (Plotplan, showing size of lot, location of.system in relation to wells, binding` .etc. must beplaced on reverse side.) <br /> NEWOINSTALLATION: (No septic tank;." seepage ;pi` per fitted if:.pubiic�ewer is available thin 200 feet,) <br /> q� t� Liquid 'Depth --`��- <br /> �oe ` <br /> -, ` ti•Siie ---j <br /> PACKAGE TREATMENT `[]' r SEPTIC TANK [ ] " ' = <br /> I }. Capacity �. .:TypeG.C �j' tea _ <br /> ---_No Compartments <br /> 11-0 <br /> „Distance to'nearest: Well... .-- Found ion__ -.-" -- ---_g-Prop. Li <br /> :. T'� <br /> ! i Total Length.- r r <br /> LEACHING LINE, [;]_ No. of Lines.-;_- Length of.each hlna.,. �� " <br /> J Q ' <br /> - e_ 'Filter Material.- -- --- - '- <br /> D' Box J._ ..Type Filter Matenall� -Y ��'4D p 1' r" <br /> / �'' .:Property Lme s--------- <br /> D <br /> '' � . <br /> istance.tonearest: Well." -- ""- Foundations" -- <br /> _ Y N <br /> De th- - ------"- --Diameter -Number. •-. x 4�=.,-- ,`Rock Filled es ❑ o ❑ <br /> SEEPAGE PIT [ l `, P " 1 <br /> - - -- Rock�'Si�e_ _ <br /> Water Table.Depth -----------------------------------------------, --- ---------- , <br /> ; <br /> Distance to nearest: *i---------------Foundation-`-----=---- - Pro Line-------' : - <br /> :. � �. .: •- ----- ----.Date-'--- ---------------�-�`"r-- '� <br /> REPAIR/ADDITfON (Prev. Sanitation Permit#_.'------ ------------- -------------- <br /> _ _ <br /> - ------------- - <br /> ----------- <br /> Septic <br /> p <br /> - -------------------------- -----' <br /> �cify Req . <br /> pistlosal Field�(Specify Relqulirements)\--'------------------: -- ---- - -- '-'-----'---- ----- -- <br /> -- ---------------------------_ - <br /> 1 - f -------- <br /> i 1 ----- ---1-..-:----- ----------------- - <br /> =------------'-----=------------------ -- - <br /> �, addition on reverse side] <br /> - ------- --- --- ---- -- - ---- <br /> ----- ----------------- = <br /> �: - - ---' <br /> ... <br /> (Draw existing and required a y <br /> I hereby testify that.1 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 Sari Joaquin Local Health District. Home owner or licensed agents <br /> F signature certifies the following: ? 1Tx <br /> "I certify that'in the performaince of the work for wh'sch`this permit is issued, f shall riot eiriploy any persori;in such manner as <br /> to become subject work a mpensation;laws of California." <br /> ± t <br /> Signed '= :Owner <br /> ] _.Title ---- ---- -------- <br /> --------=-------------=- <br /> By--------- --------------------------------------------- = ----' t <br /> (If other-than` owner) . <br /> FOR DEPARTMENT USE_ONLY <br /> �. ATE <br /> APPL•IC-ATION-AC-CEPTED B <br /> * Y. _ <br /> �.. _ D <br /> , DATE.--.------------ ------------ ------ ----- <br /> DIVISION OF LAND NUMBER--- ------------------ <br /> '-� mac• -- - --- -------------- <br /> -------- <br /> ADDITIONAL COMMENTS. <br /> t <br /> -'---- ------ — ----- <br /> -------- -------- ----------------------------------------------------------r <br /> --=------------------- <br /> -------------- <br /> -------------------------------------- <br /> -----:----------------------- ---- . _- to <br /> Final-Inspection•by.:-- 21677 REV, 7176 3M <br /> :-- - <br /> / <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 4J/� <br />