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---------------- <br /> FOR OFFICE USE; ` <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE US1�:� <br /> --------------------------------------------------------- (Complete in Triplicate) 77— '7+ Permit No------------ -This Permit Expires 1 Year From Date Issued <br /> -- Date Issued."- ��-Application is hereby made to the San Jaquin Local Health Distr-ict forra,permit to construct and install the work h <br /> This application is de in compliance with County Ordinance No 149~'and"'fisting Rules and Re elation <br /> herein described. <br /> JOB ADDRESS/LOCATIO - O r a " .. , -. <br /> - --- -- -- - <br /> E --- '' CETRACT--- <br /> ------------------------` <br /> Owner's Name:!= N <br /> J�-a.a <br /> 7­6f <br /> Address - ------ ---- <br /> ----- '� •• ^ Phone <br /> - - r .city - <br /> � ,j� <br /> Contractor's Name -__--- „� - - -- - i - " - -- --------- - - <br /> .S <br /> Installation will'Fserve: _ I License " " phone -b__�fv�'] <br /> r Residence Apartment House <br /> Motel ❑ Cour�ercial ❑ Trailer Court ❑ <br /> Number of Irving units: ❑ Other. _ G} "_- <br /> - - - r <br /> -. . <br /> Nucrber.of.'bedrooms'___ _-.-Garbage Grinder--- ;KU_ L..e <br /> )( OS <br /> Water Supply: Public System andlname- = _ : i --- <br /> Pp Y <br /> x <br /> - _ - ...------ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt - ----- ---- ----- Private <br /> i <br /> ❑ Cla e <br /> i <br /> Hardpan Y ❑ 'Pe`atYO Sandy Loam ❑ Clay Loam ❑ F <br /> {plot plan, s p ❑ ` Adobe Fill Material._.. f;�Qs t <br /> ' _.....:..,y,,�..;�YP_ a ---- ---- ---- ----showing size of lot, location of: system in relationfa ells, buildings, etc. must be placed on reverse side. <br /> NEW INSTALLATION: {No septic tank or 'see a e '' � �"�` ) <br /> P g pit— it public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ' <br /> [ ] <br /> 'SEPTIC TANK -------------------------------- <br /> � , <br /> l ize--- ---=-• , - r <br /> �( ---- -------- •-----------Liq <br /> Capacity p -= Liquid Depth..4y�r --- <br /> p yl� �.,:,.TYpe�-- - - - =- --Material�F <br /> -•.No. Compartments... . ___,_ 2 <br /> { <br /> ';. Distance-,to nearest: Well " " ` ; <br /> '- . . ------Foundation ----- tQ-------------- <br /> LEACHING LINE: Na, of Lines _ _ <br /> �r- t ) Prop. <br /> ype Filter Materiae/or�( line- <br /> pe th ne <br /> D' Box. LST I ST ength fQ-� <br /> Filter Material---.--- "_"I r r <br /> .Tota l_L <br /> t a'. <br /> 1Distanceto nearest: Well-_ - <br /> SEEPAGE PIT' �' ' f <br /> fit" Foundation lQ..�4-_-------.P Property Line.- � -------------------------- <br /> f <br /> y <br /> 1Depth....�i- _--Diameter".___ ._ <br /> ��---=- --Number.--- ---'LY :---:- - ---- ------ --- . <br /> s <br /> " # - i Rock Filled Yes ' No <br /> f 'Water TablelDepth-- ! r"xt} <br /> 1 Distance to nearest: Well--------"----- -- --------------- " -Rbek Size-_�__ <br /> d _ FF y I <br /> Foundation__-_._�i __-tL._-.- - Prop. Line. -- .' <br /> REPAIR/ADDITION (Prey"Sanitation Permit# ._ <br /> ------.Date _ = rt - <br /> Septic Tank (Specify Requirements)___..'_-"' ,.:' T ' ` <br /> I l <br /> Disposal Field {Specif R irem - - - <br /> = ---------------------------------- <br /> --------------- - - <br /> • ; ----- <br /> ... _ .. .-. ------------.---- --------------------------------------------- , . . ------ - <br /> -------- --- _ <br /> ti = ----- <br /> ----------------------------- --- <br /> -- ------------------------- - ----- ------------ ------. -- ------------------ <br /> I {Drc1w existing and required addition on reverse side) <br /> ` <br /> hereby certify that I ha�e-prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinarices, State Laws, and Rules•and Regulations of the San Joaquin Local Health District, Home owner or licensed h <br /> signature certifies the followin q tY <br /> ' g' ' � � - ed agents <br /> "1 certify that in th'e performance of the work"for which this permit is issued, to I shall not em <br /> to become.subjectjo Workman's Compensaon <br /> ti ,laws._of California." employ any person in such manneras ! <br /> Signed. .. <br /> --------- <br /> B i = Owner + <br /> Y ---- <br /> . . ' <br /> If of <br /> 1 { an owner} rife --•• - - ` <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY...-_ f ` <br /> DIVISION OF LAND NUMB <br /> ER__".__.------ ----- ---------------- <br /> -----=------------ ----------- --- ----- <br /> - -- - ----- ------ ------� ;---DATE .--- _�" . .7 <br /> --- ------- -ADDITIONAL COMMENTS-------------- -------- - -- DATE ----- <br />-------- ------ --------------------------- --- -- - - ----------------- <br /> a_ ------------ <br /> - ---------- <br /> i - ------------------- ------------------•------------------------------------------=-------------`-----'------- -------------- <br /> Final Inspection b ` . -------------------------------- ------- ---- - <br /> EH T3 24 <br /> r SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> �p F&S 21677 REV. 7176 3M <br />