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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------------- AA <br /> (Complete in Triplicate) Permit No...�lt-.__��___.. <br /> --------------------------------------------------------- <br /> Date Issued.__�: 0�7 <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: <br /> JOB ADDRESS/LOCATION 72 Z.. Lam` ket G� ------------------------- - - ----------CENSUS_TRACT.- ---- ------------------ <br /> /..� .._ �^fel lz---------------------- -------------- ---- ---------------- Phone-------------------------------------- <br /> All <br /> --------------------- ------ k <br /> Owner's Name-t--C� .e�-� .,. �.: _ ,. . _ . ._. . -- - - <br /> • Ci <br /> Address...... BGtJTGYfS-- Zi _ _ _ <br /> Zip 1 <br /> Contractor's Name--'----- - ----- - - ------------- ------- -- ----'----- License # Phone <br /> ----------- <br /> Installation williserve: Residence ❑' Apartment House.[] Commercial ❑ Trailer Court ❑ <br /> . ._ _ .. Motel ❑ . -Other:------- ---- - ------ <br /> j <br /> Number of living units:------------- ---- umber of bedrooms------------Garbage Garbage Grinde.r------------Lot Size _ I--- <br /> Water Supply: Public System an`d:name--.---!------------------------`-----------.---------------------------------------------------------- ---- -------------------- ----------- ---Private ❑ <br /> Character of soilto a depth ofr3 f et '� Sand Eli t E] Clay E] Peat ❑ Sandy Loam E] Clay Lo <br /> Hardpan❑ Adobe % I Material------------If yes, type----------------- <br /> ------- ------ <br /> (Plot plan, showing size of lot, Iocatiom of sys relation to wells, buildings, etc.:must be placed on reverse side.) <br /> NEW INVMEN <br /> ' �,septi an o age pit permitted if public sewer is available within 200 feet,) <br /> PACKASEPTIC �] ""Size____=___.-_.._.__-'._ ----_-- <br /> .._:l iquid Depth - <br /> pec' ------ ---=-TYPe-==----------•------ -Material- ------------ No. Compartments--T------:---- <br /> ----------------- <br /> tan nearest: Well-=• Foundation ------------ -------=..Prop. Line------------- <br /> LEACHI .,'of in s. - - -.Length of each line ------- ------------ TotalkLength.,' Bo Type Filter Material.____._'. ___ ._.Depth Filter Material_ ..__._ __. - - <br /> stance,to nearest: Well- .............'_.__-Foundation___ __.______- -_._.___.Property Line_. ..__--------SEEPAGfh_- Diameter....____._.. Number-------------------------------- = Rock Filled Yes ❑ Noi ,ter Table Depth : Rock Size ----� ---- ------ <br /> istance'to nearest: Well-------- ------------- .- ------.--_ --Foundation.........__..._ _.._.-_. Prop, Line--------=-----.-_-- .-_-- h <br /> f REPAIR/ADDITION (Prev. Sanitation Permit#---------------=-------- '----- <br /> .Date-------------- - ------ <br /> ify Requirements) -- <br /> ] <br /> i <br /> ISeptic Tank {Spec _ . ----------------- <br /> - ------ ---R - � iF -�--------------------- ------------ <br /> DisEposa! Field (Specify.Requirements) �--- u=_ --br . . . -------------- --- <br /> -r4c '' x..4 � <br /> ----------- <br /> - -� <br /> E -----'------------------- ------------------------------------=-------- ------------- -- --- 0 ------ ----:. <br /> ---- ----- ---------------- -- -- ------ ----------- <br /> - --- ------ ----- <br /> - (Draw existing Arid 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 /> i 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 suck manner as 1 <br /> to become subject to.Workman's. mpensation, laws of California.". <br /> Signe ----- ---- -- 0wnex <br /> / i -- t 4:. <br /> Y ==--------- - --=---- ------- --------------'--------------------=----- -- --- <br /> J <br /> --` a <br /> $ - <br /> _.Title <br /> (If otherthan owner} FO EPA�ZT ENT USE f <br /> i � 1 <br /> 1 ONLY <br /> '—'APPLICATION-ACCEPTED'-BY- A - - - -- 3ATEt - = -�-- = - ----- <br /> DIVISION OF LAND NUMBER: -- --- DATE-------------------- , <br /> ----------- <br /> ___G__..._.{__._._ <br /> ADDITIONAL COMMENTS_- <br /> ---------------------- ---- - -;=� -------------- -"---------------- -------------------------------- <br /> _ <br /> - -- --- _--- --_--- �:__ �-�---------�-� -- ------------------------------------ ----------------------- ---------------------------------------- <br /> ----------- <br /> ---------------------------------- <br /> -------------------------------- --- - ----- ---------------------------- ----------- --- ------------ '- <br /> Final Inspection-by:.. , /f �` ------=--------�-----------=-T--------- `----._Date <br /> {�L� --- <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/7e 3M <br />