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FOR OFFICE USE: V FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> f4, <br /> (Complete in Triplicate) Permit <br /> ° Date Issued---------- __________ ----------------------------------- 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: <br /> JOB ADDRESS/LOCATION L _ l T-(�� '. ----- ---------- - ------ G __ CEN TRACT--------- -------------- <br /> Owner's Name - ,��.. I}-----sh.C)N_(�'. 1�_------ . ne <br /> T <br /> ez ----- ----- P <br /> Address----- - <br /> = . ---- <br /> Contractor's Name- <br /> - <br /> 4*------------=------ --------------License #. `1_�------Phone --------------------------------- <br /> Installation <br /> _'' �--- <br /> Installation will serve: Residence ❑; Apartment House.0 Commercial ❑ 'Trailer Court ❑ , # <br /> i - Motel ❑- Other-=---_------ -..._... = �. ._¢.. _ ..i..... .r. 1 -� <br /> Number of,living units:__- _______-Number of bedro0ms.._..3__Garbage Grinder------A-4--Lot-Size--.--- .............f -_ 1 <br /> Water Supply: Public System and name ------- ------... :. - ------------ r-.- -.==5 Private. <br /> Character of soil to a depth of 3 feet: ; Sand 0 Silt❑ CI 1:1Peat E] oam Clay Loam <br /> i C <br /> f Hardpan❑ Adobe`❑ ill Mate i I__.-_.--_.-If yes, t �_ �Jx/,+� <br /> (Plot Ian, showing size of lot, location of system in r lati to'wells buildi t� m t be laced on revere i <br /> P g Y � p s side.) F <br /> PACKAGE LLTREATMENT---[(NSEPTIC Tnk:or seep a permitted if publ a er s ov ' able within 200 feet,) - <br /> se tic�to <br /> f <br /> ANK C' ` Size =/ - - ---. ---- G- <br /> Liqu'tI Depth ��t- <br /> e Capacity-.--,---i- <br /> # { p y -=-- . ---Ty Mat - - lo,•Ca{-Compartments-o ---------------------- <br /> Distance <br /> ------------ ------ <br /> Distanceto.n�earest: W Fun tion s-,Pro ; <br /> ---- ' <br /> --- - - - -- - --- ---------- P: Line-- .�P -------"------- <br /> LEACHING LINE [ ] No. of_Lines.:,---:-- _—.,,�Length.o i a.-- -- --------------------Total.Lenth.-------I----_----------- -- 'x <br /> .... 4 - ------------ <br /> 9 <br /> 'r :D' Box" a :T r Material:40- D er Material------11� �_r `--------------------------------- <br /> ` <br /> Distancato ea e11--- -------------- Found n ...------___- Property Line_. ------------ -------. <br /> S PA <br /> EE GE T [ ] Depth---- __ iameter------------ - . _ umber--- -- ---------- Rock Filled Yes ❑ No❑ <br /> { Water Tabl pth.-------- '-- - - --------=--------- -- ------------ <br /> ----- ---Rock Size---------------------------- ----------------- <br /> f . <br /> Distance t n est: Wel -.:-/-- ------------------------� -__:Foundation---,,];!iMi---------------Prop. !ine---._5 . - 4 <br /> REPAIR/ADDITION (Preva•Sanitat�n Permit#_� ~ ---- - ------------------------------------Date------;------.--------------------:------ ----_) <br /> Septic Tank (Specify�Reguiremets) ..............:__: ._ _' _�--------- - <br /> -- <br /> - <br /> DiosaSL <br /> l Field( Specify.Req.ui nts)-'-- --�, -- -----------$------ ---- ------------=---------------------------=-------------------------------- `----------------------- <br /> s <br /> e Q <br /> ---------------------- <br /> v (Draw ezistirig and required addition on reverse side) h <br /> I hereby certify that I have <br /> prepared this application csnd 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 1 <br /> signature certifies the following: <br /> "1 certify that in the performance of f he 'work for which this permit is. issued, 1 shall not employ any person in such manner as } <br /> to become subject to.W rkman,s .Compensation: laws .of California." <br /> Signed f--------- <br /> v <br /> = c __Owner <br /> ------ <br /> BY = Z.✓ = ------------------------ = -------------------- ----- # <br /> I. <br /> e <br /> Titl .�_ <br /> (If other than-owner) : <br /> : F <br /> 4 " FOR DEP MENT lJ ONLY` ; t <br /> -- ---- -. *----- ---DATE.- -"' --- '-- <br /> APPLICATION ACCEPTED BY -- - <br /> , <br /> DIVISION OF LAND NUMBER: ----- ---- -------=-- ---=-- --- ------. -----'. .DATE------------------------------------------------ <br /> ADDITIONAL <br /> --------------------- -------------- - <br /> ADDITIONAL COMMENTS-----:----------------- ----- <br /> --------------: ---------- -- -- = = -------------------------- <br /> --------- -------- --------------- <br /> ---------- <br /> ----------------------------------------------------------------------- ----------------------------------------------------------------------------- --------------------- - ------- ------ <br /> ------------------- -------------------7---- ------ '------ - - --- ------- - -------------- <br /> -- <br /> ---- <br /> -- - - -- -- -- -- ------------ <br /> -- ---------------- ---- <br /> � y <br /> Final-Inspection by:: - -�- Date ------------ <br /> FK <br /> _. <br /> er+ i3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7 3M <br />