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FOR OFFICE USE. qx V FOR OFFICE USE: <br /> �; tQQ - 36 APPLICATION FOR SANITATION PERMIT ,. /--- T <br /> ------------- ---------------------- ---------- - Permit No.- - - -( <br /> ----------------- (Complete in Triplicate) <br /> ---•-------- ---------------------- --- <br /> - ' Date Issued___/_7 <br /> -G—_�?_ <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-existirgRules and Regulations: <br /> JOB ADDRESS/LOCATIONT - ----;r_O al o"-?-----pe--------- __ --------- ---------------CENSUS TRACT----------------------------- <br /> r <br /> Owner's Name------1M_0 T------------------------- ------------------------------------------------ t----------------------------------------Phone---------------------------------•---- <br /> Address---AO------_I'_q-*'_f!7T'-----p'f-------- -------------------------------------------city----7�C_Irl---------------------------Zip----- - <br /> Contractor's Name_A0*Of44A0r-*T7t',p--._A&Ar1fMi0f_._X'4.O--__A_* eA---__-_License2.____Phone_4�/J'=-S�' 4tJ7X4 <br /> Installation will serve: Residence Q1 Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other----------------------------------_--------- <br /> Number of living units_____________ ___Number of bedrooms-----1-----Garbage Grinder------------Lot Size__, 8_X_L_a__ __'_.___________.__.------------� <br /> Water Supply: Public System and name---S_A a__0*_*_P_*4--!___-K/_toCo-___ ------4w-S*L.-L----------------------------------Private [� <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 1.� <br /> Hardpan ❑ Adobe X Fill Material-.. If yes, type_-_..________-____-__-_.-____ <br /> (PI elan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> STALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200.feet,) <br /> P C GE TREATMENT [ ] SEPTIC TANK Size----L 104-____Gam+' �-��" ---'--------------Liquid Depth___S _________-____ <br /> Capacity---/S®Q------Type---------------- ------Material-------------------------No. Compartments------------'�------------------- <br /> Distance to nearest: Well-------------------------------------------Foundation________.__-______--____Prop. Line___--______-__--.____._. <br /> LEACHING LINE �. ]X No. of Lines__ __ _ _ ___-.__-- Length of each line------------------------------Total Length - <br /> 'D' Box ``___..Type Filter Material_ _-_-__-__.__-_Depth Filter Material ___ ------------------------------------------------------- <br /> Distance <br /> --___. _ <br /> Distance to nearest: Well----.-----------------------Foundation-------------------.--------Property Line____ ----------------------------- <br /> Depth_.___.7___---- <br /> Diameterl_0. 4.ZQ___Number-----------------------,.-------- Rock Filled Yes X No <br /> r^J C"I Water Table Depth------------•--------------------------------------------Rock Size---LkZ-----� liet-C&------� <br /> Distance to nearest: Well-------.---------------------.-------------Foundation----?-3- - <br /> ---------.Prop. Line---S----- -------------REPAIR/ADDITION (Prev. Sanitation Permit#--_____________________--___---_--------------Date---------------------------------------------- <br /> Septic <br /> _________.________.__-.__ _--_Septic Tank (Specify Requirements) ------------.!9�L Lo..------------------------------- ------------------------------------------------------------------ --------- <br /> Disposal Field (Specify Requirements) o_XxQ = hL'EP---- _ .0i4'D------------------------------------=----------------------- <br /> -----------•------------------------------------------------------------------------------------- --------------------------------------------------- -------------•------------------------------------------�f� <br /> -------------------- --------------------------------------------------------------------------- ---------------------------- ------------ ------------------------------------------ -----� <br /> (Draw 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 sut to Workman's Compensation laws of California." <br /> Signed----1 o ---XZ;> - - -- ------_------------------------------------Owner <br /> -----------------------------------------Title------------------------ <br /> (If other than owner) <br /> DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------- ---7----- --------------------------------------------DATE -------- <br /> DIVISION OF LAND NUMBER--- -------- ------------- ----DATE------- ---------- <br /> ADDITIONALCOMMENTS------- -------------------------•-- --------------------------------------------------------------------------------------------------------- ---- <br /> -------------------------------------- ---------- -- -----------------------------`--------------------------------•---- -- ----------------------------------------- ---------------- <br /> ------------------ - <br /> -- --------- - <br /> Final Inspection by:------- <br /> Date__-_ _ _- <br /> ----------------- - ®`�-----��---- ��. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M <br />