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` R R <br /> FOR OFFICE USE: �— � <br /> APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: <br /> -------------- <br /> (Complete in Triplicate) Permit No.--.------------------- <br /> --------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued.___1/_?F <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--.-. dy3 M �i11� x <br /> ---- - ----------- ---------- <br /> Name.------9C 4 B� TRACT <br /> ----------=--- --- ---------------------------------- <br /> - <br /> s �, .., ,.. � -. -- - ----= -- ----=- - - -- . - -- --.Phone -----./8�_' yc!_7� ---- <br /> Address ------ - ------------- -Fl?-c �G� ��lr� <br /> = F <br /> . . _: �-- .. .. .: ,.. City----------------------------------- <br /> c, ------ ---Zip- <br /> Contrator's Name-- - - -�A f2 �� <br /> License 2�l i <br /> `I `� <br /> --- -- - ----- -- ---Phone---- �' 3 _�___5___�__ <br /> Installation will-serve. �" Residence Apartment House Commercial Trailer Court ❑ <br /> i <br /> Motel ' <br /> i ❑ Other `------ ----------- -----=---------- <br /> Number of living units:,-___i__---_--Number of bedrooms;__-�J._-__Garbage Grinder------- Size__. .9Cke�GQ <br /> i ------- .- ---- <br /> Water Supply: Public System.and name--------- ---------------- - <br /> ---- ------------- <br /> --=------------- -------------------------_-- Private,® <br /> f <br /> Chpracter of soil to a depth of 3 feet: Sand (� Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe'❑ Fill Material- ---------If yes, type________________________- -_ - - <br /> (Plot plan, showing size of I location of,system in relation to wells, buildings,etc. must be placed on reverse side.) r <br /> NEW INSTALLATION:' {No septic tank;or_seepage pit-permitted if public'sewer is available within 200 feet,) <br /> r TREATMENT [ 1" §EPTIC TANK e ( X.... <br /> [ J , Size_' --- ------ '� i h 7 <br /> PACKAGE TREAT --Liquid Depth.---- ----------- ----C-4 <br /> f Cap city _J200— (_,*`9TYpe----- = '-------- .Material------ ---- <br /> - _ ,.No: Compartments <br /> pi Distance to neares01 <br /> t;.WU----------- ------ Foundation - ----------- -Prop. Line-----S--------- ---- <br /> LEACHING INE [ J No. <br /> = ofLin'es_.----- ----i--- '; Length �f each line.. - ' -- . !d <br /> ---- ---- --------Total Length ------ <br /> - -- <br /> D, ox ---------T e Filter Me?terial /Z <br /> -CA--Depth Filter Mater <br /> iali <br /> - <br /> Dista ncsto nearest: Well __1.l ' <br /> bi_ .. ., , �- ' <br /> � -- Foundation - ___ .- ----------Property Line_- <br /> o- '. F ; <br /> wr <br /> SEEPAGE Pll [ 1 _ Depth- -------------- iameter----------------------Nuirsb r----------- ---------------- Rledock Fil � es❑ o' <br /> I <br /> Wat r Table-Depth__'______ ----- - . <br /> ' - - ----�-Rock 'Slze'----- ----------- <br /> k _ . - ---------------- ----------- . <br /> Distn e.to nearest: Vl/ell } - _- t3 L�rfr� <br /> Foundation -_-.__--'_-----------_- <br /> ( 3s3 fProp Lije----------------- <br /> REPAIR/ADDITION Prev. Sanitatip Permit#-'._:__- __ - <br /> is s ---- <br /> • ---------------=--.------- Date--- ------_ .:� --`~�---- ------ -] <br /> Septic Tank (Specify Requirements)._ <br /> 1111 _ - ------------------------------- --------------------------------------- ------------ --------- <br /> Disposal Field (Specify Requirements) - - <br /> :1 � -------- I f <br /> . )----- = <br /> - - :. . -- --- -- . <br /> v (Draw existing and required addition on reverse side) -� <br /> 1 hereby certify'that'rhave prepared his-app{ication-cmd--that-the-work will be done in accordance with San Joaquin County <br />( Ordinances, State Laws, anitd Rules an Regulaftns—of—th"an Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies theo)lowitt <br /> "I certify-th t in 'the performance"of:the work for which this peirrriit is is3 ed, I shall not em to an <br /> to become subject to p Y Y perso in such ma ner.as <br /> I Work .Cbmpensatiarr. laws of California." f ( <br /> Signed-------- ---- <br /> Owner <br /> -------------- <br /> ------- <br /> --------------= _ <br /> (If 'other'th owner) t <br /> FOR-DEPARTMENT USE ONLY' + { <br /> APPLICATION ACCEPTED. BY_t_. ` - = l l <br /> -- ----------------------- ------------ DA <br /> TE.---------- --.7 a <br /> DIVISION OF LAND NUMBER___________________ <br /> - ----------- <br /> ----.DATE. <br /> ADDITIONA COMMENTS-_ - ----------= � � - -- -- <br /> ---- ------------ -------------------------- - <br /> ' - ------------------------- <br /> --------------------------- ---------------- --- -- -- ------------------- <br /> -.- <br /> --------------- - -- ----------------- r <br /> Final Inspedtion by = = . . ( t f� �[� <br /> = = a <br /> EH 13 24 <br /> - ------ a--.- <br /> — SAN:J0AQUIN L(5C_A!H-ALTH)DIST•RIG7, F&5 21677 REV. 7/76 3M <br />