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FOR OFFICE USE- FOR OFFICE USE: <br /> — APPLICATION FOR SANITATION PERMIT <br /> Permit No.---7�:fe <br /> ------------------------------- ----- l <br /> (Complete in Triplicate) <br /> ----- ------------------ ---------------- ,3-/3- 7 P• <br /> ---'----- Date Issued-------------------- <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: v , <br /> JOB ADDRESS/LOCATION- ,--- ' .-- �--�--- ' 1� <br /> � v- = ---------------- -- --- - ---.CENSUS TRACT.----- ---- ----------- --' <br /> ` �= /� ---Cit .. -�__' Phone-:=�--- {- <br /> Owner's Name.---- __.-:....- -Lj 1 C-�'44------------------------ -----------------•- --- ----------.----- <br /> Address--"--- ---� =--w----- " d-5-- ------ - " ----- <br /> y .9 iv%F /� �, <br /> . . .., .Contractor'sName . _ ------------------- -----:License #- +�/ � Phone..- <br /> .�..... o..--... ' f <br /> Installationl will serve: Residence �' Apartment House.E] Commercial ❑ Trailer CourtEl <br /> tri Motel D. Other--=------ =------ :-----:----'=---=---- ; <br /> Number.of:living units:_.__].'......Number of.bedrooms-- _"_.Garbage Grindea__ .Lot�S%e --.- Z_---- --- <br /> ----------------------------------- <br /> Water Supply: Public System and name---------- = _ -----------------------------. ---------------------_ --------------- -- _------Private <br /> Character o .soil to a depth of 3 feet: Sand ❑ 5ilt ❑ Clay ❑ : Peat❑ Sandy Loam} Clay Loam ❑ t <br /> Hardpan❑ Adobe ❑ Fill Material--.-- ---If yes, type---- _------------------- <br /> 1 � - , <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> a NEW INSTALLATION-- '(No septic tank .or seepage pit permitted if public sewer is available within 200 feet,) 1 <br /> e <br /> -Li ui. <br /> PACKAGE 1kREATMENT ` [ .1 '--SEPTIC TANK [ ) Size--------------------'-----=------------=--------------- q De Pth---------------------------- <br /> ` ... Capacity--- - --------------Type_- -==--= --- ------Material------- ------------------No. Compartmetnts------e-------------- --------`--- <br /> .... <br /> Dist Wel nearest: Well-=---------- - ------------------ --------Foundation-- - =--------------.-Pr P• Lin <br /> LEACHING LINE\/ I'1 - No, of Lines---------F------ -------Length of each line.------.---.----------_�°.tart Length : ' eJ------------- <br /> 'I f k f 7 k <br /> t 'D' Box_"....-'---Type Filter Material- ------ ------ Depth Filter Material-. --- ----- _--._ -- . . ;----- - <br /> r D.�stanca to nearest: Well ---- Foundation .-_. t Property Line..:.. �Z---------- <br /> V <br /> r 1 E <br /> SEEPAGE PIT [ l •eP ----------- f --= � , Rock Filled Yes ❑ No <br /> th�.� Diameter--- Number-- = --=-----= <br /> d { <br /> f. . . Water Table Depth - �� Rock Size---- L- -- --- -- <br /> -�%---�-�-Distance to nearest: Well -.-- __ - 1r�f'- -Foundation.=:= `- ----------Pr of e_- <br /> REPAIR/ADDITION(Prev Sanitation Permit#NF :-- ----- ------- -- -Oat ' . --:' --.---- ----- <br /> Septic Tank`(Specify Requirements)--...._ _.~ J` �- Yx�`f� ------ <br /> l Y T <br /> Disposal Field (Specify Requirements)__--:..---- ---=. -- --- -- .- = - 1 <br /> ._".....__.. ...t.............. .�....__'_...._._.__. ) h�__ ___ --__ __ - ".---- --_____" --------- ------ ----r---------- -- -.-_..------------------------ <br /> I <br /> ..-.- -- -F--- <br /> ..._1- .� <br /> -- ------`L ---- -'-- = � - •. <br /> ¢ --^-(Draw exfi fs .and-rer{riir.ed addi_ t_ion on reverse side) <br /> have prepared this'a o'71 do and'that the work will be one in crccordance with San Joaquin County <br /> hereby ceify that I i , P p pp ' f'' ' r or licensed agents <br /> Ordinances,! State Laws; and Rules and Regulations of the, Sari Joaquin Local Health DistricdHome owner 9 <br /> signature certifies the following. t'U � } <br /> "I certify that4in the p6gormance of.the workor which this permit is issued, I shall not employ,ar'!y pirson in such manner as <br /> if <br /> to become !subject t o an'�ompensation laws .of .California." a <br /> Signed T - .� ' ° -� - - ------ --- --.----Ownerl i <br /> ' = <br /> ------'----------------------T --- <br /> Title----- --- -------------- ---- ------ -- ------------------ <br /> ------------- [-=------- <br /> i(If­6th& tiian'owner) { <br /> ! - ; FOR DEPARTMENT USE ONLY 1 r <br /> i I k f <br /> APPLICATION(ACCEPTED BY.".:: t---- ------------- <br /> DATE.-----'----------- --------------- ---DATE._ -------- <br /> DIVISION OF LAND NUMBER --' -_- -_ :---- DATE -----'-�---- ---------------------------_ <br /> . -�.. <br /> ._ -- --- <br /> 1 ADDITIONAL COMMENTS------ ----- --- ------------------------ - `-- - ---'"`- -- - -- -------------------------------- <br /> E <br /> ---=------------------=-------------=-- --- ---------- ---------------------- ------------------------- _ <br /> ---- <br /> s - ---- - -- ------ --- ----- - ------- ----------- - -------------- <br /> ----------- - ---- ---' <br /> ------ ------ - --- --' ---- -- <br /> ` Date ..- �, <br /> Final-inspectionaby:"= _ /_�-"�---' ----- ------ - <br /> i' Eli 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes 21677 REV. 7/7e 3M <br /> E <br />