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t <br /> Ac FOR OFFICE USE: - FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT . <br /> ---------------------- ---- 7 ..y <br /> (Complete in Triplicate) <br /> Permit No.____.----�--- -----.. , <br /> -------------------------------- —/z - 7 <br /> - ------------ - <br /> Date Issued_________ _______7 <br /> --------------------- ------------------ --------------- This Permit Expires 1 Year From Date Issued ' <br /> Application is hereby madAtd Q San Joaq iLE co aISHealth Disthict.�fdr,asperrritVo,cons�O�and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing4Ru�les and Regulations: <br /> 30a F- 4 �/sem <br /> JOB ADDRESS/LOCATION..--'-------- -- ---� r <br /> � �- FiSUS TRACT. - <br /> Owner's Names Phone - <br /> Address ----------- d- CY p ..-Zip ,t <br /> Contractor's Name.- --__!/t_ -__---.-----.-._- �Q--------------�i('[icense #-____ ¢4-U..- <br /> --------------- <br /> --Phone---------------------------------- <br /> Installation <br /> -------------- ----------- -- � <br /> 3 <br /> Installation will serve: Residence, Apartment House.0 Commercial ❑ Trailer Court,❑ F �r <br /> Motel=H -@ter —= <br /> Number of living units-----------------Number of bedrooms, __ Garbt'Grinder __-. _..--_Lot Size-- -1-..- __.____ +' <br /> -- <br /> Water 5u�� I Public System and name----=------:------�. '--�-= -: ^z � ��� ` �-------�-------------'-------------[--Private <br /> Character ci.soil to depth of 3 feet: San Silt❑ Clay ❑ Pea ❑ Sandy Loam ❑ Clay Loam Li <br /> Hardpan Ado Fill Material.............If es, type____.___-___--_.__---..__..--. <br /> r. P ❑ Y 4.. <br /> (Plot plan, showin i ize of lot, location of system in•dation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW 1NSTALLATIO�p (No­sepfic tank -or seepage pit permitted if blit sewer is available within 2L}0 ffeet) <br /> PACKAGE TREATME T SERTIC TANK Size - - -- L.la----------��i 66uid; Depth-- �-- <br /> Capacity Type-----=-- --------------- Material_. -_No. Corjpartments------------------------/-------'"---0 <br /> Distance to nearest:.Well__-� Q--------- ----- ._-=-Foundation__��_____--------.Prop. Line-- <br /> : ` 0- <br /> LEACHING LINE [ No. of Lines_--.,3----:--------------- Length of each I I -,� ----- Sotal Length..------a�1- -____;---_-__.___ 0 <br /> / 1` �� r}e ,�dr �r a <br /> D' Box------ -_-Type Filter Material_ -_-----/-1$ep h iter MaterlaL.__-____---.--__ -------=-------------- <br /> tWell--l-49- ,S-a - <br /> Number f = .Property Line ----- -. -------- <br /> I � Distance to nearest: LZ____�--.Foundation__�� w.. : <br /> SEEPAGE PIT [{]7 Depth---------- ----Diameter.___----.--.-.------ _____- Rock Filled Yes ❑ No <br /> ' Water Table Depth--------------- -----------.Rock Size------------------------------------------------- <br /> Distance-to nearest: Well_ <br /> --------Foundation-- ,----- ---- Prop. Line-- ----------------------- ; <br /> REPAIR/ADDITION (Preva on SanitatiPermit#-- -.-- <br /> ___ _ <br /> . Date <br /> Septic Tank (SpecifyRequirements) - ------ - --------------------------------------------- - P <br /> Disposal Field (Specify Requirements)-------------- ------- ---- ------------ = = ----- -- j ------------- ------------------- <br /> . �-�IX ---- - -- --- --- -------------------------------- ----------- -- <br /> w. <br /> ------- --------------- -----------------------------------------------=-------------------------------------- -- ---- - ------------- <br /> (Draw existing and required addition'on reverse side) <br /> 1 hereby certify that l-have-prepared-this-apps.,q�tionAand-tha"he-work-swill-be'done--in-accordance-with-San_Joajuin County <br /> Ordinances, State Laws, and Rules and Reg u c:tiorri-i af� San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: "` m <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 subject to Work n Co pensation laws of Californi <br /> Signed- ---- - -- ----- -- -- --------- - ---- ------- - ...............--- Owner <br /> By -- ... ------- ------------- <br /> = --- -------- --- ---- ------ ------------------ <br /> , - : `... <br /> (I other than owner) ' <br /> R`DEPART ENT USE ONLYt <br /> APPLICATION ACCEPTED: BY- =- =---- -------- --------------------- DATE.- <br /> DIVISION OF LAND NUMBER------------------------ --------- ---- DATE.---------------------------- <br /> P <br /> ADbITIONAL <br /> --- -------- <br /> ADDITIONAL COMMENTS____________________ _ <br /> ------ l <br /> ------------------- -- ---- - ------------------- --------------------------------------.- - ------------------------------------- ---------------------------- ------------ -- <br /> l : <br /> ------------=----------------------- -------- -- �- - ----- ------------------------ -------------------------------------------------------- <br /> ! A ------- - --------------------- - - -------- <br /> ------ - <br /> ---------- ----------- ------ -------------- --- C <br /> Final Inspection 'by: „_ .... --- -Qate---^ ----------------- <br /> 7 <br /> EH 13 24 SA JOAQUIN LOCAL HEALTH DISTRICT gas 216» Rev. end 3M <br /> E <br />