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`FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No. ._ - -Ff <br /> -------------------------------- --- ------- ---- -- -- <br /> Date Issued'_;;L_-7 <br /> ----------- ----------------------------------------- This Permit Expires 1 Year Frorrh`Dcite Issued <br /> Application is hereby made to the San Joaquin Local Health District for a perMit�tb construct and install the work herein described. <br /> This application is made in compliance with Count Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------------- -------- - ,- ----------------------------------------------------------------CENSUS TRACT—e4e --� <br /> -ex GRA'' <br /> Owner's Name-.- 1 •e✓i. Phone 3y-_3310 <br /> Address 'l v -II--�----------------------- ------- -------City --- ----- - --- --- ..-Zip a RC1------- <br /> Contractor's Name-- -- - -------=-------------------------„-License #-c�o- -------Phone r ---- �------ <br /> --: ; <br /> Installation will carver Residence Apartment House ❑ Commercial E] Trailer Court [jh' <br /> # _ Motel ❑ Other <br /> Number of living units:------ -----NOmber of b'edrooms---- ------Garbage Grinder-.--------_-Lot Size------- ---------._--------.- <br /> Water Supply: Public System and n`me�_ --------------------..----------------------------------------------------------------------------------------------------Private � <br /> Character of soil to a depth of 3 feet: Sond1_Q Silt[] Cloy [] Peat ❑ Sandy Loam Clay Loam ❑ <br /> 1 Hardpan ❑ �A�lobe'❑ Fill MaterigL-._- _If yes, type--- <br /> ----------------------------- <br /> (Plot plan, showing size of lot, location of�ystem,in relation to!wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION: "[No septic tank or ts&epage ipi-perrrritted 'if public se4wyer,iis available ithin 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANKk ,� Size---_� 5 ��- - q p <br /> uid De th <br /> Capacity.. YP Material `- No. Co partments ----------- <br /> Di sante � nearest. Well___'�Q-O-------------------------------F�sUndation'w-��-=--__----------Prop. t,ine_��____ <br /> k ------------ <br /> Distance <br /> LEACHING LINE [`t No, of Lines-:---� ---------- Le gth of each line.----- 5----------------- Length.--:1-SP------------_____.__-___-_ <br /> i [ `r r <br /> # 'D' Box_-/-y---Type:Fllter Material /I,t. .Depth Filter Material--------------------------------------------------------------- <br /> a"7 ---.Property Line_--_- _- - - -- <br /> -Distance to riea�esf•VVe�I -- �-'-------------Foundation---- ------��-------------- - - - ---------- - -- <br /> �^] Depth__ -- ..��1Si_ ` �.--Number------------c-r------- ----- Rock Filled Yeses No ❑ <br /> Water Table Npth,-t� 1•--------y--------------------------Rock Size----------- -----1 <br /> ] <br /> o <br /> `V__^ � r Distance to near6st: Well _"Foundation_------------___ Prop. Line <br /> -:+ ______ __ _ _________ T <br /> r <br /> IREPAIR/ADDITION (Prev. Sanitation Permit# t4 =---------------------Date----------------------------------------_----___------ - ---- <br /> SePtic Tank (Specify Requirements}----_._--.._-- :.,;-----=--------------------•;---------------__-_-- <br /> Disposal Field (Specify Requirements) ------ -----------------------------------------------------------------------------------I------------------------------------ <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 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 t <br /> signature certifies the following: r <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 subi o orkman's ompensation laws of California." <br /> Signed--------- ------ ---=-----=----------- ----- ------ -- -----Owner��"�-r y <br /> BY------'---- ----- ----- --- ' ----------- --- ---- ---- ---- - Title--- - ------ 4RS; .............. <br /> 3 (if other than owner)” <br /> t <br /> FORD ARTMENT USE ONLY' <br /> APPLICATION ACCEPTED BY-------- �' ------ ------------------ -------------------------- DATE.. . 2 �� ----- ---.------ <br /> DIVISION OF LAND NUMBER__------------------------ --------- -----.DATE------------------- <br /> ----- <br /> ADDITIONALCOMMENTS----- ------------- --- - - --------------------------------------------------------------------------------------- -.------- --------------------------------------- , <br /> ------------------------------------------ -------------- ---------------. :--- ------ -- ------------ --------- ---------- „ --------------- ------------------------------------ i <br /> ------------------------------------------------------------- ---------------------------------------------------------- ------------------- <br /> Final Inspection by:----------------- ------------------------------- - Date <br /> EH 13 24F&5 21677 REV.•7/76 3M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br />