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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 7.".- ..-.-5.N <br /> Permit o <br /> (Complete in Triplicate) Perm // �J <br /> ••••-•......••••. ...----..........-. ......... This Permit Expires 1 Year From Date Issued Date IssuedU�.:c -7/ <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 exiissting Rules and Regulations: <br /> JOB ADDRESS/LOCATION.. <br /> � ./'� •. fC .�°Y.e{.� � G is!J- .--- t`�'-•-...--CENSUS TRACT..._........................... <br /> _ . <br /> Owner's Name.. c-�r...--�7. d' .._.T. � .............. . .-- . . . •-•- Ph on e_.19_p-9_ <br /> Address"AA359ti.... ..C�. "1 .._e.. ---Ci r'e/�i 11,---- 7� Zi ". LS sr C <br /> Contractor's Name.4� --- ....--.License Phone__ �`5i . <br /> Installation will serve: Residence ❑ Apartment Houma ❑ GommArciial_❑. Trailer Court E]Motel F-1Other_ ,e,,h, <br /> Number of living units:------._.--..--Number of bedrooms............Garbage Grinder----------"-Lot Size.-""1J�./�`- .... ----_"-._-_.............." <br /> Water Supply: Public System and name----------------- ..........................................................- -.-.------.-- Private^tel <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material__ __R -._If yes, type.............. <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) Qui <br /> NEW INSTALLATION: (No septic tank or seepage pit p irmitted r 0 <br /> if public sewer s available within 200 feet,) �� <br /> PACKAGE TREATMENT ( ] SEPTIC TANK [ " �a /Size. XL "X..t1✓rZ---. .- <br /> P Y O� / �. �'.L�.�.� �- P Liquid Deft <br /> Ca acit ZQ1. .-._--- ZlType .- _6...Material .Lt <br /> -:N .Com artments_--------------------------------- <br /> lstance to neare$t: Well---/fQ......................."......Fou ndation...l . __ ".-.."".Prop. Line.- .......... <br /> ..� <br /> LEACHING LINE No. of Lines.....--............ Len theach line.--.- .--- Total Length ......................... <br /> 'D' Box./.......Type Fitter atena .--�. �z-'-..Depth Filter Material ---------------------;------..------------------""-. <br /> �- ----------- <br /> Distance torn�arest: Well-- . - .".---__.Foundation.---"-.IY-------------Property Line..-------."-.-_-_-.. <br /> SEEPAGE PIT ( DepthIS......Diameter.."U-. ._Number-- -. - Rock Filled Yes No <br /> Water Table Depth."-...-. r-------- .... ..".Rock Size....I-.��.—�Z-........... <br /> 1 <br /> Distance to nearest: Well.------- _- .......-".-------Foundation"-.....$, . __---_.".Prop, Line./ .�7 <br /> REPAIR/ADDITION (Prev, Sanitation Permit#------------------•--------------.- ---------------Date-.................-------------*"""""-"-"-----) <br /> Septic Tank (Specify Requirementsl... ....._.. ". il ---------------------- -- - ........ <br /> Disposal Field (Specify Requirements) <br /> -- - --- - ---------------------- ---- ----- -------------------------- ------ ------- -- ------I------------------- - ------------- ------ ----------- <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 <br /> signature certifies the following: <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 s ' -ct to Work en's Compensation lows of California." <br /> Signed _... ........ .......... -----...Owner <br /> BY --- ----- - - ----- --------------------------------------------Title..... --------- -- ---------------------. ---.------------------------- <br /> (If other than owner) <br /> FOR D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----".. L. - ----------- <br /> .. d <br /> - ---- -- ------------- .....DAT <br /> DIVISION OF LAND NUMBER -- ---------- ------------- -- --- DATE.... --------- <br /> ADDITIONALCOMMENTS--- ---------------------- --- --------•-•-••--------...--------------------.-.--------...------- ---•----------_ --------------------------------- -- --- --. --- <br /> ---•-•-----•--•---------------------------------------------- ------------...---------•--- -••-• -•------------- ----------------- .................... -------------------..------------------ <br /> ------------------- <br /> . ".. <br /> --•-------- -------------------- -- ---------- <br /> Final Inspecfion by:.." Datee 7� S" <br /> vim-54 <br /> �' � F&S 21677 REV. 7/76 3M <br /> EH 13 24 $ N JQ4iN LOCAL ME LTH DISTRICT <br /> ''� �/ <br />