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k <br /> NOR OFFICE USE: I. <br /> II APPLICATION FOR SANITATION PERMIT FOR OFFiCE'USE: <br /> „�--------------------- <br /> (Complete in Triplicate) Permit No. —?--- --6-, <br /> Date Issued.__.—F"e�­77 <br /> This Permit Expires I 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-=.--'- _ -/ 57= ---�` <br /> ---' ------------------------------- <br /> NSUS TRACT.ner's Name.--- C- ------- <br /> - <br /> 3 l <br /> Phone--- <br /> Address <br /> ----- ----------- J: r� y <br /> p� 3 <br /> �s I ,..t :{'" -------------------------- ---- ,:'-Cit ---T..-:.:� --- - -- --" --' `-- ZiP�--' --- - <br /> Contractor ± Name---- <br /> 1; <br /> ame _ y-. C _ r <br /> ----------------- --License # ? :. "Phone <br /> Installation will server*! Residence Apartment Ho. <br /> use.❑ . Commercial ❑ Trailer Court ❑ <br /> ;! Motel '❑ Other--- <br /> Nu'm' ber <br /> Nu bei of livingunits:___ Id -- <br /> r 33 <br /> 9 "___Number of bedrooms ...__-_Garbage iGrinder_:. __ Lbt SizfeXA�- <br /> Wafer Supoly: Public S stem and na_ me_ - <br /> ` P Sand ❑ Silt Cla ! .-Private <br /> Pp Y� Y -- -- - <br /> �� -- - - ---i <br /> Character o soil to a depth of 3 feet: ❑ Peat❑ Sandy Loam ❑ Ciay Loam , <br /> r^Hardpan-❑ Adobe ❑ Fill Material--------- es, t . <br /> .: <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be p(acd on reverse si`de.} , `�Yy <br /> NEW INSTALLATION: :(Noy septic tank or see a e . it ;. J '' � > I V <br /> p g p permitted if pubicfewer iavaifablewithin 2p0,feet,) <br /> PACKAGE`TREATMENT [ ] SEPTIC-TANK <br /> -t- --- ----- Liquid Depth _ _E~_ <br /> (,. --------------- <br /> Capacity'/ ' =TYPei 'lr. �TMaterial I ! I N o p r m -'` f E ! <br /> -1 o. Cpm a eats---' " ---i -- --- --' <br /> Distance:to.nearest: Well___. f s!; [ ! / <br /> = ---- � .Foundation. Prop Line _ Q <br /> o t <br /> LEACHING LINE [�] No. ofaLmes_:. .__ __..Length of each line_t__ _ _ _ -!: -".Total Len th.-�__ _ "` <br /> �- // r l g t <br /> I I ; 'rial_I�•Y�/, Depth Filter Material �� �` # - _ <br /> D' Box Type Filter Mate <br /> ___ <br /> Distanca to nearest. Well_. C�---__. �� / <br /> Foundat�op '�" �"— <br /> _. --- ---- o erty Line--- -� -►------ <br /> SEEPAGE PIT .. I <br /> ] l Depth--- -- � - r <br /> Diameter - N'umber - --------------t 4< Rock Filled Yes L) No <br /> ` ock Size:" "" :-" <br /> � � Water Table Depth---- ----------� ----- ---- ---'------:- -'- <br /> ----------------------- <br /> Distance to nearest: Well--'---_-.-i__ _:-"- ------------- <br /> ""-__ ------Fouridafion'.;_ _ -- :------------_- <br /> 6d� - Prop. Linl '-------- <br /> REPAIR/ADDITION-(Prev. Sanitation Permit#_________ _________________" <br /> ------ -�•=�-. -,Date---'-- ---VIA-- <br /> Septic Tank'(Specify Requirements).________.____-__ ""______._ <br /> --------- -- - ` <br /> - V ------------------------------ ---- <br /> Disposal Field (Specify Requirements)-- ---- ----- • <br /> - <br /> = )------- <br /> -------------- ----- <br /> _ _- <br /> ------------------- _ <br /> �.. t <br /> - t1 <br /> -------------------- (Draw exi ----- '......sting �equiredadditionnrever , <br /> side ,, <br /> I hereby certify that I have prepared this applicatiomand`that�the-work wile-done-in�dccordance with Sair ijoaquin County <br /> Ordinances,, State Laws, and Rules and Regulations of the", Sari Joaquin Local Health District, Home owner[or•licensed agents <br /> signature citifies the following i � eJ k <br /> i t <br /> "! certify thpt in the performbnte of the work for wh€c�this permit isisssued,,'I shall not em to an <br /> to become,`subject to kman's. Compensation' lawseof Ccilifornia.. ' �� l pplay Y person manner as <br /> e in 'such <br /> t <br /> Sighed <br /> ya. <br /> BY = ------- Title_ <br /> _-. --------------------- ------------ -----.�. <br /> � (lf other 'than owner) � � [ � w t <br /> ..f. <br /> FOR'DfPARTM T"SE-ONLY'. <br /> APPLICATION ACCEPTED BY_..___ <br /> DIVISION OF LAND NUMBER- -" ' DATE ------ <br /> ---------- <br /> ---------- <br /> --- <br /> DATE ---� •- <br /> ADDTIaNAI.-COMMENTS _ __ ---s- ----- <br /> ------------ <br /> --------- ------------ --------- <br /> `' ---- -- ---------- -- -------- <br /> ------------------------------------------------------- <br /> i. -.--------- --------------------------------------------- <br /> --------- -- <br /> .- --------------------- <br /> _________________________ <br /> Finai'!InspectionY " 7 <br /> EH 13 24 <br /> Date.--/Z" <br /> `SAN JOAQUIN LOCAL HEALTH DISTRICT Fps 21677 Rev.7176 aM <br />