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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------- ----------- - Permit No._.71"__�;/D3 ) <br /> (Complete in Triplicate) <br /> ------------------------- ---- ---------------------- - -3 a <br /> Date Issued__S__ ______? <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 existing Rules and Regulations: R F t [ <br /> JOB ADDRESS/LOCATION �,�� -S~-' -- 1' a .AAA4Z------RA------------------------i--------- ----_.CENSUS TRACT.-------------- ------ ----- <br /> Owner's Name. rG_4 ql_.. -------------------- ----- --------- ---------- <br /> s--------- ------------------- - ------------- -------Phone----------------- ---------- <br /> .--- t <br /> Address - <br /> ��~7-S.'�---- ---- �.�_ Li9,0��_ -�:--��- --City— - ------------yip----- --------- -------- <br /> Contractor's Name,+MSL_ _dl'1" ".0----54.-OR'40of--- _-License #_; _4j_Z2-...____.Phone_44.s f?a _!74A$7/./ <br /> R , <br /> Installation will serve: Residence Apartment House.❑. Commercial ❑ Trailer Court ❑ r <br /> : .Motel.❑._ Other__---_------ ':.. <br /> Number of living units:-_ --- - ___Number of bedrooms____-7____Garbage Grinder-------------Lot Size.I14, <br /> Water Supply: Public System and name____..________-:..-,.,_-,._____.._ _ _ <br /> Private Rf <br /> Character of soil to a depth of 3 feet: Sand ❑ ;Silt❑ _Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ i #, <br /> Hardpan ❑ i Adobe k Fill Mater ial...._........If yes, type________________________________ <br /> {Plot plan, showing size of lot, location of systemin relation to wells, buildings, etc, must be placed on reverse side.) r �, <br /> NEW INSTALLATION: No septic,tank or seepage pit permitted if public sewer is available within 200 feet,) V' <br /> PACKAGE TREATMENT [ ] SEPTIC-TANK 'Size---� p�___. _____________Liquid Depth__. _________--____c� <br /> Capacity--1--A-cv-0Type _=Material No. Compartments--------� <br /> --------------------- <br /> f <br /> Distance to nearest: Wei --------------Foundation-------4!1____------..Prop. Line.---- ------------ -- j <br /> l i i . <br /> LEACHING LINE 'No,. of Lines-__'____.___ _ --- Len th of-each line--------- _G._=_,______.--Total Length.,."._A_7Q----------------- _______ <br /> ., ►_ •D' Box....X----Type Filter Material"__ �_ C<tt_ Depth Filter Material------- --------------------------------- <br /> + Distances to nearest: Well__--- -04------'_____Foundation--_ r <br /> - Property Line - _- ---------- ----- <br /> SEEPAGE PIT [ ] Depth----------- '___Diameter. _____._: ;.->._Number----------_:-_ -_______________ = Rock Filled ,Yes ❑ No <br /> $ Water Table`.Depth--------- --------- -- ------i-----Rock Size I <br /> - ------------------- - - ------------------------- <br /> Distance to nearest: Well._-- -------------=-- ---'---�'.,--- ---T-.Fou ndation--------------------------Prop, Line----------------------- <br /> '-Do <br /> ----------. _ ._. <br /> REPAIR/ADDITION {Prey. e. <br /> c <br /> Sanitation Permit#_-------- - --- - Date = = :1 <br /> Septic Tank (Specify Requirements) --__- ---=--`-__-- i---------------------------------------------- ------------------------- .° <br /> Disposal Field (Specify Requirements)_._'^',1p-_A _J . .__-_P_ie _ _ew 4-_-- / !� �f'---_---_-------=----------- <br /> t. .t <br /> ------------- ------------------------------------------- '---- ---.-.-- -S-- ------ -----.. - -- <br /> i-. -, g -: -q ._ _„�,,,,�>;------------------ - :- <br /> --- ' -= ----------------------------- --------------- -- -- ---- -::--- - ----- ----- �--_------------ °�� side) "- <br /> [Draw existin and're uired addition on reverse <br /> 1 hereby certify that:l 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 su ' ct to Workman's. Compensation laws of California." . <br /> Signed---- , <br /> ... -Owner <br /> i By-i------------------ --------- ----- --------------------------------------------- ---—_- -Title <br /> _ ---_---- --------------------------------- ---­----------------------. _ <br /> I ([Pother than owner] <br /> F F R DEP TMENT SE ONLY. <br /> i APPLICATION ACCEPTED BY. -=-- - = - - ------DATE.-- <br /> DIVISIONOF LAND NUMBER.-- ---------- ------ ----------- ----------------- ----- ------------------------------ ------ -------DATE.-------- ---=-- ---------------------`--- <br /> ADDITIONALCOMMENTS------------------------------------- -------- ---------------------------=------------ - ------------------- ----------------------- <br /> F <br /> ---- <br /> ---------------------------__ ------------------------_----------_-----------_-----------------------.________.__________--_____.-_____.,_____________._ <br /> I _ __________________________ .-.__-______._ <br /> c � a . ----- <br /> --- ------- uk --------------------------------Hate.---- <br /> Final Inspection bY:_._ <br /> EH LX G 'r- <br /> r <br /> 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M <br />