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FOR OFFICE USE: FOR OFFICE USE:
<br />APPLICATION FOR SANITATION PERMIT
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<br />Permit o.....-_,_.-_..
<br />(Complete in Triplicate) Perm.'.._._. l
<br />__......, _._„ .....,�,w...w... w.......... ...�.......,......__... .�....,- .._-.__... ....�,., - 'may
<br />This Permit Expires i Year from bah► Issued Date i55Uet�...�
<br />........ a
<br />Application is hereby made to the San Joaquin Local Heal Disti"iti'f6i crxp'ermit t Instruct and install the work here n described. ?
<br />This application is made in compliance with C ,ty Ordinance No. 54 d existiri Rules and Regulotions: I
<br />Jab ADDRESS/LOCATION , {� s' 1.�'i 7 ' �14� ._ _ i1.-,...._., ..,. d4r^P.0. CENSUS TRACT h ..
<br />Owner's Name .. ' (1£�.LtilYt. t'IZ j ►. _tr'i ��,JtL`7`�2t2 R"o�.s..................... :............Phone,
<br />`,.,......l✓'C'•........ city_ _ 40,
<br />«t� ._._...... i
<br />Contractor's Nome._., r te-' i ib'.fS':Jd. `.«.y�.,�4d' ,. *x •......License #r�o...Phone.a
<br />Installation +rails serve: Residence } '. Apartment }-louse .F] Commercial E] Trailer Court n
<br />1• Motel C Other
<br />Number`dfVving units:._. i.._ _„Number of.bedrooms,2_..... Garbage Grinder.. _ . Lot Size_.. !1�., .._... �"✓.�.
<br />Water Supply: Pubc System and name... t _... Private
<br />Character of soil to a depth of 3 feL't: Sand Silt [j Clay ^. Peat-�i Sandy Loom fI Ciay Loam
<br />., � .. Hardpan Adobe Fill Maternal........ .....if yes, type .-----.------.....,. ,......
<br />(Plotplan, howl»g side a lot,` location of system in relation to wells-,-buildings; etc.--must•be-pla d- on reverse-side.)- ..
<br />NEIN 1INSiALLATION- �(tlo--septic-, taar k or»seepage pit permitted if public sewer is available within 200 feel,} "
<br />s�.._',.�"PACKAGE TREATMENT SEPTIC TANK Size.�...�...�.............. m_ ..Liquid D
<br />epth_
<br />j4ypeCompartments .*..S.... � � _... ..
<br />I
<br />r
<br />Distance to_rfearest: Well.-. Foundation....
<br />LEACHING LINE No.. of Lines,-, .ff Len
<br />�.! Total Len
<br />peFrter teriab' CA,
<br />Depth Filter
<br />r- Distance to nearest: Vlell..... Fraundation a d. r fix
<br />Property Line ....W+'... t ..
<br />tt
<br />SEEPAGE PIT rX Depth r a.-Diameter... x ....Number .....-. .. alt..._ rl Rock filled Yes NOD
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<br />) Writer Table IDepth.__._t�4._..14.. _ .....Rock Syke.,. ...-; �... �.� r
<br />Distance to nearest: Well._.,...
<br />�?��....................Foundotie�n.�...... Line
<br />I 't
<br />�e E �
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<br />REPAIR/ADDITION (Prev. Sanitation, Permit #...._ -.�._.............................:.
<br />..... Ddte ".,t%l
<br />".?a_,_,_.,._.,.......... �
<br />Septic Tank (Specify,Requirements)i. »...............
<br />p eld (S .......................
<br />Dis osal Fi pe¢,fy Requ cements}..... ..:�'"�
<br />i.
<br />_..............
<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`waccwdonce, with San Joaquin County
<br />Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health'bistrict, Home owner or licensed agents
<br />signature certifies the following:.
<br />:r
<br />"I certlfythat in the erformance of the work foi which this permit is issued, i shall not employ any person in such manner as
<br />to becom subject orkman s Camp nsation ws of California."' _.
<br />At
<br />Signed...
<br />By '._... __..., ..:. Title.....
<br />(if otter the owner) '
<br />�_. fOR' DEPARTMENT USE ONLY
<br />APPLICATION ACCEPTED BY.....C:.... _.. _..............DATE.......
<br />...
<br />DIVISION OF LAND NUMBER......................... .._.,......_..-_...,........ ....-,... DATE__--... �.,.
<br />ADDITIONALCOMMENTS... _..--...... ... ._..__... :_...... ._........;............._._.,. .,,_....__.._..,.._-.........,.
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<br />e
<br />Final Inspection Bate
<br />EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT cgs 21677, asv. 7l76 au, �
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