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� FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT fG <br /> I, APermit No.-Z11,_=aZ-`-�d- <br /> ---="�----------- -------------------------------------- (Complete in Triplicate) <br /> Date Issued_.--.--��-- <br /> ------- ------- ------------------- --- <br /> --- --- '----. -�-- ---__ � This Permit Expires 1 Year From Date Issued <br /> -------------- ---------------- -__.._.---F__._---._ _-- <br /> to consI the <br /> Application is hereby made to the/Son Joaquin <br /> Localunty Health DisNot for anpermitd exist ng Rultes and Regulations: work herein described. i <br /> ruct and instal <br /> This application is made in coma _ <br /> rACT-------- <br /> wst _ . <br /> ------- ---- EN TR <br /> .-CENSUS <br /> JOB ADDRESS/,LOCATIO 3 _7` 7,3: <br /> 1 + ] ------- ----- ------ <br /> Owner's <br /> ---- Phone <br /> Y ��T_.� <br /> Owner s Narne_.���=-- --- -e - ----- . - -- ------------ - ------------- <br /> -s T ;7 ; �- F G -- ---- -- ------- - �i}� <br /> Address---------- on ? T <br /> : , License # +F.:3 -Ph e-. - ! <br /> Contractor's Name___ -- -- <br /> SSS----- <br /> -------- ---- <br /> e> ( !, # Commercial ❑ Trailer Court ❑ - <br /> lnstallation;wiil serve: � Residence. •Apartment House ❑ - - <br /> `t <br /> Motel.0 1 Other a;- -- -------- ----------- ------- <br /> - yq t - �' l <br /> h i" '_*•tee �,—'�w°'�-. F-Y '�'-: :L / C.-C�/L�.__ ._ <br /> +� *^- tuber of bidroot - �j'.�-Garbage Grinder__ _- _ _-Lot Size ------ ------ <br /> Number of living units:-, _h(v . s _ .-Private <br /> a Water Sup�ly: Public System and--name +� .. --;-- ;�_ .-- <br /> = _ `�" "' "" Sand Loam Clay Loam ❑ y <br /> Character of soil to a depth of�3 fee d ❑ `•Si3ty❑' Clay ❑ € Peat ❑ Y <br /> f Hardpan ❑ ' Adobe❑ -"Fill Material if yes, type <br /> buildings, etc, must be placed on re}erse side.] <br /> (Plot plan, showing size of lot, location of system i . . e a ion`•to �w,ells, <br /> NEW INSTALLATIOW (No'septic flank or seepagk,pit permitted`if public sewer is available within tui feet,] V <br /> r <br /> +d •4� � .. �=.,5_ 7� =-C� ------ ------- ------- ---Liquid Depth.-------------- <br /> SEPTIC <br /> ------" <br /> SEPTIC TANK Size-_-_.- I <br /> PACKAGE TREATMENT [ ] -- --- <br /> 6 7 � �rz.�,,(�m6terial_- ��- . omportm nts____n -f <br /> -Capacity, ------- - # =_Type - 4 <br /> No C e -- - <br /> r <br /> �f <br /> I } Prop. Li <br /> Distance to nearest: Well______________ =-"f <br /> ._Foundation_____ <br /> -,LEACHING'LINE No..of.Lines_----- ---=------'-- ..Length.of each.Brie.-.---'�-®-._--_ .:-- --Total Length --- -- ---.- - <br /> p i <br /> r 'D' Box----- Filter Material_. C Vii----Depth Filter Material ms --�_ I --------------------------- <br /> I (4- <br /> ------ <br /> + <br /> i j /(j t-¢- Foundation � "74------= Property Line -- --------- <br /> 'Distance to nearest: Wel! * '' <br /> _ _. - <br /> + ! --------------Number--- - -- -------- <br /> SEER <br /> ° R Y <br /> r i El <br /> Rock Filled es ❑ 'No <br /> De th --.=------- Diameter.= <br /> SEEPAGE PIT l P. - ------- -- <br /> • . oc ,ze._.------------._-...... .... ... <br /> • `- Wdfer-Table Depth - . � --•.- -• -R k S <br /> ---- <br /> '_ Pro - -- <br /> y s <br /> istance to nearest: Well •-----Fouridation._ p. Line <br /> REPAIR/ADDITION (Prey. Sanitation Permit#_______ --------------------- <br /> --------------------------- <br /> Septic Tank (SpecifyiRequirements)---------=----------- ---------- ------------------------- <br /> ---------------- <br /> ----------- <br /> --------------- <br /> Dis osal Field (Sp4ify Requirements)-------------------- - <br /> ------------------------------- <br /> i --------- --------------------------------------- <br /> r------------------------ ----------------------- - ----------- <br /> -------------- r : --- - '--------------- <br /> --------------- <br /> - <br /> _.�,. � l�Draw existing dnd required addifiiota-or}-reverse-side) <br /> I hereby certify that'1 have prepared this application and that the work will be.-done in accordance with San Joaquin County <br /> andsRifes and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> Ordinances, State Laws, <br /> signature certifies the following: �rs*n- <br /> in such manner as <br /> "I certifythat in the per�brmbnce of.the work-for which this permit is issued, l shall no employ any <br /> to become subject to INor man`s'Campensation laws of California." <br /> r -- -Owner <br /> Signed <br /> -------- <br /> - - -- <br /> I fi.. - Title_ <br /> = r <br /> If other than owner) k, <br /> FOR'DEPARTMENT USE ONLY <br /> DATE.---- '�-y -/ - --------- <br /> APPLICATION ACCEPTED BY------- --- ,--- - - <br /> DATE. - <br /> DIVISION OF LAND NUMBER... -=.. : ------------- <br /> ADDITIONAL COMMENTS - <br /> t <br /> ------ -------------- <br /> ------------------------------ <br /> ----------- -------- ---------------------------------------------------- <br /> ----------- <br /> ------- -------- --- -------- <br /> r ^'�-- � -��----"- '------ _'Date- ------ ---- <br /> ---- - ------------ <br /> ------ - <br /> Final Inspection by:__._--. -- -- \`: l� i�� _ t� -., - F&5 21577 REV.7/7h 3M <br /> EH 13 24 SAN JOAQUIN`J'OCArL.H ALTHl<DiSTRICT <br /> 1 <br />