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yj FOR OFFICE USE:, '* <br /> FOR OFFICE USE: $ ` <br /> APPLICATION FOR SANITATION PERMIT �g a 9 a <br /> f g Permit No._ _ - - - -- , <br /> ------------------------------------------------------- <br /> (Complete in Triplicate) i <br /> -----: ;� Date lssuec!3-9 -7--`l <br /> ---------------- This Permit Expires 1 Year From Date Issued <br /> r ade to the San Joaquin Local Health District for a permit to construct and install the <br /> Application is hereby mwork herein described. <br /> This application is made in compliance with County Ordinance NO. 5A9andexisting Rules and Regulations: <br /> TRA <br /> 1 +►� + - <br /> ' -._ ._. ..._-.CENSUS CT- ---- ------­---------------- <br /> ----- <br /> --- --- --- ---- - <br /> JOB ADDRESS/LOCATION --!_-/ " �- { k <br /> _. <br /> j--:. : Phone ----:---- -- ----- ------- ---- <br /> ------------ ---- - <br /> Owner's Name4 ---:--- --- fir- r3 <br /> Address - ry. zi <br /> 7 ----- --- --- <br /> _ r - a ---------------------- <br /> Contractor's Name-- --_- - — '-- -- License #--- _ Ph ne <br /> en <br /> Installation will serve: Residence p� Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> 4- <br /> t Motel ❑ Other <br /> ' <br /> Nu _ jj <br /> ber of living units:____--_ _—Numbe'r of bedrooms - .'-Garbage Grinder_: Lot,,Size__-.- <br /> { <br /> � � - ----- <br /> ----- -- - -- - Private <br /> Water Supply: Public System and name---------------- ----------------- -----------------------_----_--- -----.---------------- _------- <br /> Character of soil to a depth of 3 feet: ' Sand ❑ Silt❑ .=Clay❑ Peat❑. �Sad.y Loam Clay Loam ❑ y i <br /> :j,- F Hardpan ❑ 'Adobe,❑ Till Material: If yes'type---x-- -- ----- -- `----- i <br /> (Plot plan, showing size of loft, location of system in relation to wells, buildings, etmust be placed on reverse side.) + <br /> E .; <br /> NEW INSTALLATION: (No:-!'septic tank or seepage :pit permitted-if-pubic sewer is available within 200 feet,) # <br /> SEPTIC TANK ['] Size ° -= -------------------------- <br /> ---- <br /> - - -,----Liquid Depth--------------------------- <br /> PACKAGE TREATMENT [ ] ,. <br /> 4 Material - ~"""-'---=--__No. Compartments-----------=----------------- <br /> _ Capacity---- =---------------Type . = =----- ------ <br /> i j° Prop. Line -------- <br /> No. of Lines_ _ :.Length of eac = Foundation - -- ----- <br /> I Distance,to nearest: Well-_--'__:.�-----------=--- -- <br /> i LEACHING LINE_ [�.].. h line--=-------"-- _.Total Length._ . <br /> ial <br /> - ------------- <br /> D' <br /> -- --�. <br /> - <br /> � <br /> D' BoxeType Filter M`ater „w"-r- _ FeI---- --- ------- ---- --- ---- -- - ---- <br /> Distanceto nearest: Well--------------- ------------Faundatian_._�-�� -:-----_ __ _PropertyLina------------------------- . ... <br /> = _ <br /> R A k Filled Yes N <br /> o <br /> k Drameter_ � - <br /> I <br /> ------Number--- ---'-- ---- _SEEPAGE PIT Depth ..r---- -Rock Size--- <br /> Water TableDepth - °------------------- Foundation----------- -------- .Prop. Line ---- ---------- ----Ii- <br /> - <br /> Distai <br /> nce-to nearest: Well-----------------------.--- <br /> -------------------- <br /> T]. . <br /> REPAIR/ADDITION (Prev. Sanitation Permit#------------------------- --- --- Date._ - <br /> I <br /> --- -- -- ------ <br /> ( Septic Tank (Specify Requirements)---- -- - -- --- -----= --- - - - - <br /> Di osa field ( ecify Requirements} -,-e - <br /> r ------------------------------ <br /> ------------ ----- . -_ --------------- <br /> ------------- --- - --- ------- - <br /> "" (Draw existing and required addition'on reverse side - J` <br /> I hereby certify that7l have prepared this application and that the work will be done in <br /> accordance with San Joaquin County <br /> Ordinances,' State Laws, and Rules and Regulations of-the-•San Joaquin Local Health District, Home owner or licensed agets <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which his permit istissued, 1 shall not employ any person in such manner as <br /> to become subject to Workman:s Compensation .laws:of California.". - <br /> s t <br /> - <br /> I <br /> �..".-.-O...w <br /> n <br /> er <br /> -----ned_ -------- --------- -Sig -'- <br /> -------- <br /> ----r <br /> ------ <br /> --------------- - <br /> I Title .- <br /> -------- <br /> ------------_------------------ ______ <br /> (If'Sthe'r than owner} / M <br /> FOR-DEPARTMENT USE ONLY <br /> • Z. <br /> APPLICATION ACCEPTED. B•Y- -- = / ' ----=------------------ <br /> ,DATE <br /> ------- - -- <br /> DATE.-_-- f <br /> DIVISION OF LAND NUMBER'-- 7-------: ---'-- - .- <br /> ADDITIONAL COMMENTS---------------------------------- ------- <br /> ------------ ---------=----------- <br /> --- <br /> ------------------------- ------ -------- -- -- <br /> - -------- ---------- - <br /> --------- ----------------- - <br /> ------------------------ <br /> - ---- --- <br /> ----------------- <br /> Date_-`T--Z'- <br /> Final Inspection by:--------- - <br /> F85 24677 REV.7/76 3M <br /> Et+ 13 24 SAN JOAdUIN LOCAL HEALTH DISTRICT <br />