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wTw y FOR OFFICE USE: <br /> -ter ;'. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No.....7.---- <br /> -----•------------- ....... - ......... (Complete in Triplicate) <br /> ai! <br /> ------------------------------------------- -------- Date Issued.- 15' '. ..7F <br /> _.- <br /> ........ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the Son Joaquin Local,'Health District for a permit to construct and,install the work herein described. <br /> This application is made in com lipnce with County rdinance No. 549 and existin Rules and Regulations F <br /> p�',, ?yCENSUS TRACT <br /> JOB ADDRESS/LOCATI N _4 <br /> :Q.._...... '.-.lr t ....=L Phone <br /> •s' r j *"1 <br /> Owner's Nameld .+� t .. - ai-xLC' 'Zell <br /> �.�. .. ------ --- <br /> 3, x Cit. ..Zip_ �- <br /> Address.--.._ f,,! ( g j � <br /> Contractor's Name..:.IVIr :�V A. �: : - . l_ .. - <br /> --....License <br /> ne Z �Z <br /> Z ,�.tf Pho <br /> tnstnllafion will serve: Re's'idence❑ Apartment House E] Commercial=❑ Trailer Court (�]-� <br /> '.-M6Tel: Other .-------=, ... <br /> Number of living units:--- <br /> =.... �.-°_-Number of bedrooms_-- rGarbage Grinder--�---- <br /> Plot Size.--..- ...!... <br /> ----Private <br /> Water Supply: Public Systm and name ----------- ---- -------- - ------------ --•--- ------- <br /> e <br /> Character of soil to a depth of�3 feet: Sand ❑ Silt El Cloy 171 Peat L] Sandy Loam 0 Clay Loam ❑ ^ <br /> _ Material . . --- If Yes, type----- ---------------- <br /> Hardpan E] Adabe Fill <br /> (Plat%plan, showing size of lot, location of system in relation to wells, buildings,"etc. must be placed on reverse side.) <br /> y <br /> NEW;INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ~ -' Size - ------------------------ ---- --- - -- <br /> --- ...----Liquid Depth.--------- ------------� <br /> � �Ma#erial./..1Q�?� C)P- No. Comportments-_-..71___------- <br /> Capacity../�-() ? . JJ <br /> 4 - Foundation------«f�. ... - Prop. Line.. <br /> i Distance to nearest:.Well.-.-.;,.: - / <br /> Total Length -..1_ .Q-..... <br /> LINE ( ] , No. of Lines ._-- LengtFi;:af each line--- - - --------- <br /> LEACHING ;. --------- ----`- --- ---- ---- <br /> p' Box.... ..;.Type Filter Material-.�. A! It Depth Filter Material-_�-...� ---- <br /> �. V -r I <br /> - , Foundation-------- - Property Line-..---- -•-- <br /> 'r <br /> ,: . Distance to nearest: Well ,-�_:J��-°'�- --: . <br /> / 7�y nn -- Rock Filled Yes kJ---"No <br /> SEEPAGE PIT ( ] Depth ---�sS ..Diameter <br /> -.__-V. ---. ':':Number.-----dam <br /> ------- --.Rock Size.._..s?� <br /> Water Table'Depth.--...---.f C.�-� --.'.�.-� -= - � <br /> _._. <br /> ` nearest: Foundation.... .(�.( ...._..Prop. Line. <br /> Distance to nearest: Wel ---;- <br /> .'; <br /> e <br /> Date- ---- ---•-------- -------- -------- <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--- ----=--- ---•-------- <br /> i Septic Tank (Specify Requirements)--- _' ------ -------------: ---- <br /> ! Disposal Field (Specify Requirements)._ .--.-..----- <br /> a --------- - --------- --•---------• ------. --- .. <br /> .......... ...•-- ....-- ... " - ---------- <br /> _ _ _. _ _- <br /> .s,F r <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 ocxortlance 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 /> F signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, )"shall not employ any person in such manner as <br /> I to become subject to Workman's Compensation­Iaws of California." <br /> Signed.- --Owner , 01 <br /> D ..... . <br /> iBy... = than Title..- <br /> ; - - <br /> her <br /> (If of <br /> FOR DEPARTMENT USE ONLY <br /> • _ ---.....-...DATE ..�~-�- rr-� �..... ........... <br /> APPLICATION ACCEPTED BY----- ----- . <br /> DIviSION OF LAND NUMBER_------ `'1 ------ DATE.... <br /> ........-- <br /> ADDITIONAL COMMENTS .......... .. ............ - -------------------- <br /> - -- <br /> --- .......... --- <br /> ----------- ....... <br /> .... .......... <br /> j - --- -- <br /> --Date .6 • --. ._-- ------- - --- <br /> Final Inspection by:---. �- - - <br /> F&S 21677 REV. 7176 <br /> 3h <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />