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t <br /> rOR OFFICE USE: i FOR OFFICE USE: <br /> ,,-.APPLICATION FOR SANITATION PERMIT -- G_��� <br /> y,- Permit No--- -- - --------- <br /> -------------------------------------------------- <br /> ----------- ---------------------------- --- (Complete in Triplicate) <br /> ------------- ----- ------- Date Issued--- a <br /> -------- <br /> 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- _. <br /> < ..---�---,tl -- Td�-�l � ----- -; CENSUS TRACT -- ---- <br /> Owner's Name- -1{ tfi .. . _=z :. <br /> ��Pho II -------------- <br /> ------------------------ <br /> - ----� <br /> Address. <br /> ------------------------------- - ..._ i# -- -07 <br /> -� 1 -' ------ -- ----- City ., <br /> L �• 2 J- <br /> Contractor's Name. ' ` �...47---- - --------•------------ -------•-------- License #_ �7.. .Phoneme, <br /> '----- <br /> lns#allation�will serve: Residence'❑:Apartmen _Hi Uu e.❑ �ommerciai` 'Trail'er'Court <br /> � � <br /> E ' Motel ❑ :Other---/Y�AZ/4--/017= .. ' <br /> . ... <br /> Number of living units:--- of bedraoms+ ____Garbage Grinder__r__._`_-._Lot Size--._=G -------- Private <br /> Water Supply: Public System and namef - ----- ----- -- --`tea -- '`� <br /> Character of soil to a depth of 3 feet: Sand ❑ _Silt p Clay E Peat ]`� n-y Loom Clay Loom ❑ <br /> ' Hardpan ❑ Adobe E Fill Material------.----=!Iffyews,, typ�_M-PVA---------a------- <br /> [Plot plan, showing size of lot, location of system in relation to wells, buit"din`gs;.et�:: must be placed on reverse side.] <br /> NEW INSTALLATION: (No:septic tankor-seepage pit permitted if public sewer i5 a, aiiable within 20 feet,) g !� <br /> PACKAGE TREATMENT [ ] SEPTIC-TANK '[''] j' Size'--�!r ------------- ------------Liqui Depth---------------------- --- A <br /> Capacity-/ 'TYP ,P ------=` '----- --No.t ompartm ts. <br /> Distance to_nearest:.Well_:._ - �_---------------- --- -- ' <br /> t 1 <br /> --- ` e' �� Material <br /> I d__ _ � Foundation.' ---------------.Pr' p. Line = �3 <br /> LEACHING LINE . [ 1 - No. of Lines-',-. ._Z - :--..Length of each line.--- ----------- Total Length.---- ------------------------ ----- <br /> - , [ 1 O/ <br /> D' Box..._ __.._-Type Filter MateriaL�/ Jl ..Depth Filter Material-.___- y -------- -------------- <br /> Distancafio riearest:Well_ __________ _ ___Foundations ___.-------_ _..Property Line.. Ji ___.____ <br /> , � . ° <br /> - -- - <br /> ' Rock Filled Yes ❑ N <br /> o <br /> SEEPAGE PIT De fh"-_:---'-- --Diameter _._ ------------Number _y ":"' - - -----WaterTable Depth - ----��--- ------•------_- ------ cSize: <br /> , <br /> t Distance to nearest: Well--':----------------- - = Fon`dation.._ Prop. Line . <br /> --------------------------------c.',.�---- fie =• = ---- <br /> --------- <br /> REPAIR/Ala I pIONyPreq:Sanitation Perm i## ---- -- - == a 1 -`-- ----------------------- <br /> Se tic Tank (S ecif Re uire i nta)_�:. } <br /> ---------------------------------- <br /> Disposal Field (Specify Requdiemenfs) ------------ ---- ----------- -- ---=----- ----------------- <br /> - <br /> -- - <br /> i:: <br /> ------------- - _ :. <br /> -- F <br /> -� ` = ------------------------ ---------------------- <br /> -- -- - <br /> ----- -------------------- ----- . .-F <br /> i <br /> f ' �'(Draw existing and required addifion•, n}everse side) i <br /> I hereby certify that I have prepared th slapplicdtion and that the work witl.be done in accordance with San Joaquin County ; <br /> Ordinances State Laws, and Rules and 6gulations of. the San JoaquiW ocal Health District, Horne owner or licensed agents <br /> signature certifies the following s # <br /> I r p -�� Rte}►�. <br /> 'I Certify that in the pe ce,of.Ate work for which'this i ermit is issued, 1 shall not employ nny irson'in such manner as <br /> to become tsub' ct to a n's pens ion laws of California. . , <br /> 1 n <br /> SignedL/ / ----- - _ .-:_ Cn^'� <br /> ( 'Title--- <br /> (If other than,owner) ` <br /> " ;FOR•DEPARTMENT USE <br /> r <br /> O-NLY'c' -- <br /> D TE <br /> APPLICATION ACCEPTED / <br /> DIVISION OF LAND NUMBER--------------° ------- ------------ - a--------------- - -DTE <br /> f > fie _ t.1-7- --40----- <br /> ------------------- <br /> - -___. :rW!.'`��[ � -err-- x_^"�..�" ---------------- <br /> ------------- <br /> --------- <br /> ._.. <br /> ADDITIQ�IF,L COMMENTS`.:_, l,/ - - -- - - <br /> -------------------------------- -- ----------------------: ---------------------- ------ --------------.-------------- ------------------ ---- <br /> s,.�.a _`- ' _a------------- ---- --------- ----------- <br /> ---------- --- `,"r` <br /> ,d - - ---- ' <br /> __ <br /> -------------- ---------------------------- D 7 <br /> Final-inspection b . __ a <br /> -- ----------- `"^- te... <br /> Py,.,my='.'----� - - � -- - - -.- - .• F&S 21477 REV. 7 6 3M <br /> EH 13 2a SAN JOAQUI OCAL HEALTH DISTRICT ' <br />