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I' <br /> FOR OFFICE USE: at 40- ;. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION,PERMIT _ <br /> (Complete in Triplicate) Permit No..Z_7_-4s <br /> ---------------------------- ---------------------------- <br /> Date Issued--f i----------- <br /> This Permit Expires 1 Year From Date Issued1� <br /> Application is hereby made to the San Joaquin Local Health District4or a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 4,9tancl existing Rules and Regulations: <br /> k � - - . - ., r � .- . w --- _�.. , , _,,..._A. -7- <br /> JOB <br /> 7JOB ADDRESS/LOCATION...._ __ Q_'_ j ..._. Gf1/ �O_t -_ CENSUS TRACT__ _... <br /> A � _ _-_ : _r �. �_. ----- <br /> Owner's Name � C� <br /> ----------------- -----------. - ---------------,_. ;. _ -- ! hone. <br /> Address- ---�--- �----- ---- ' fiz�P - 1�-%-- -------------------�---�-- <br /> -- <br /> ' <br /> Conactor's Name... ,G. �-�1 s -_s <br /> Gtt _'_Lice�nse # ,*6-W_`— __--Phone'`, ;7,n/�r <br /> Installation <br /> .will serve: Residence Rli;. impartment Ho�use4❑-'i m`mirciaal`D Trailer Court'❑ <br /> . ,,,�. .r.. �• Motel [] Other �r4, <br /> Number of li in' units:--:.- _ __ umber_o.f bedrooms <br /> g 1 Garbage_Grinder Lo Size.• _ ' <br /> d <br /> Water Supply: Public System and 1 arrie s. :._. ._ i i ______ _Private I <br /> - , <br /> Character of soil to a de th of 3 feet: Sand :Silt Clay I o t <br /> p ❑ ❑ y ❑ Peat [] FS.rdy- <br /> Harclp6ri!L <br /> Loam' Gay Loam �, 1 <br /> k Adobe ❑' 'Fill'Material_.._:.......... .---If if es, e-��"' ___.___- <br /> YtY p - <br /> (Plot plan, showing size of lot, to dation of-system in relation to.vyells;`building's etc�must be placed on reverse aide <br /> NEW INSTALLATION:: 1JNo�septic tank .or 'seepage pit-permitted if public sewer is available within 200 et,} <br /> PACKAGE TREATMENT =�. k rSEPTIC TANK. ° <br /> ( ]' +A, [ ] Size - - ;---�' -- Liquid Depth - - <br /> �� Material �1 <br /> f Capacify'_ .._., ----T e -----------="-- <br /> Distance.to nearest: W Ilp._..__,_--_-__ - -Foundation_. No. Gompartme.nts----------------------------------� <br /> = - Pr p. Line----- <br /> LEACHING LINE. [ ] No. of Lines-:--- ! 1 <br /> ...Le'hgth of each I,ihe i------------------ <br /> ----- :--- T al Length ------- <br /> _ ' ---.-- _ r _ <br /> - V -- = <br /> D' Sox--A--------Type Filter Material . bepth Filter Material '. ..._ -... .._____ __ _______ r-_. <br /> j 1 � , .... = ' -------------- <br /> SEEPAGE <br /> { <br /> t f o nearest: Well.:... ----- d n <br /> l I . . ; . . ----- - --- - <br /> �. <br /> Fours atio <br /> Depth '.- <br /> Distance {{ ` Property Line I 4� - t <br /> T .� ] - D'iameter- ----------------Number- -----------1 <br /> SEEPAGE PI, .. � _ ------------------- R 0 No,- <br /> ock Filled Yes . <br /> `-----Rock Size------- ------------------------------------ --- <br /> ,, Distance to nearest:Well- _.__._ <br /> ater a e ept ---------- ------=--- =- <br /> 1 Foundation --------------------------Prop, Line '----------- <br /> REPAIR/ADDITION (P�ev. Sariitatiorl-Permit`#- - - Dte <br /> ---------------------------- <br /> Septic <br /> Septic Tank (Specify 12equirements)__...______'_�/_ - . _. gip '=': <br /> 1 <br /> Disposal Field (Specify Requirements)--------------------= ------------------------ <br /> ------------- <br /> I - - -- ----------- <br /> ---------------------------------- ---- --_ f ... . . - - <br /> ---- --------------- ----------- = ------------ ---------- _ <br /> --- -- -- ---------- <br /> (Draw'existing and reguired�addition�on reverse side] <br /> I hereby certify that ly have repared 'this application•,a that the wark``w ll be done in accordance with San Joaquin County ; <br /> Ordinances, State Lav and Rules and Regulat o s of the San Joaquin'Lbcal Health DistrictHome owner or licensed agents . <br /> signature certifies the following: , . gig <br /> "I cern that in the <br /> certify I iperformarice of'.the work;for which this Permit' issued, I shall not etriploy any person in s ch manner as <br /> to become subject to. <br /> workman's. Compensation laws of iCalifornia.� ... <br /> 1 1 � .. <br /> Signed------ -- rte- �-. p ' `".� <br /> - Owner <br /> { ------- <br /> By---------------- ---- ------------=----------- Y om'T <br /> _ itl ------- <br /> ------------------------;. - -- <br /> t t (If'other than owner) .`. ""�' , f... <br /> " FO `DEPARTMENT-USE-ONLY� <br /> APPLICATION ACCEPTED BY _ : - � \1 :__ * s� � DATE., �� -_ ._ f J <br /> DlVJSIOI�iAf:..LAN.D.NUMBER._.__ - <br /> �_ - <br /> --- --- - <br /> ADDITIONAL COMMENTS---------- <br /> .....� <br /> - ------------------------------------------------------------------------ <br /> ------------------------------- <br /> - --- <br /> --------------------- - - c. <br /> ---- --------•------ - ------ ------ , <br /> ------ -- -- -- - ------------------------------ <br /> Final. <br /> ------- <br /> --------------------------------- <br /> _ _ <br /> --�7 ---- --- -----'----- <br /> Final Inspection b - - -- --------------- --- -- - ---- -------------- <br /> _ -Date ! <br /> Y �., �. <br /> E" 13 2a SAN J AQUIN LOCAL HEALTH DISTRICT F&3 21677 REV.7/76 3M <br />