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FOR'OFFICE USE: 04r FOR OFFICE-USE;- " <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------- - Permit No.----7 7 <br /> ------------ G . <br /> + (Complete in Triplicate) 4... <br /> -----�----------' ---- ------------------------------ Date Issued.-�a--l-i-:7-------- <br /> ----- ---------------------------------.__-__..- This Permit Expires 1 Year From Date Issued <br /> �F <br /> Appli cation is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describeeddt <br /> This pplication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ^}� Glag'--__CENSUS TRACT.-___.._----------------------- <br /> i JOB ADDRESS/LOCATION-- --��-���-_.�_`J- _ .- �---- . !r�°------�--- <br /> Owner's Name. ------ /1 Phone <br /> ---------- l-� . - <br /> I <br /> i Add�ess. fvr�-2 - ---- ----------- <br /> -- -- - ----- --------------------- _City _ ..:_ _ Zip t <br /> - <br /> dM s. e, .� --------- <br /> r Contractors .Name x - � pr.. /C -d License #.-. Phone. <br /> .: _..�. <br /> i Installation will serve: nw Residence F1,.. Apartment House.❑ Commercial ❑ Trailer Court �1 <br /> v" -Numb Mdtel ❑ OA. <br /> #her = .� <br /> r Garbage Grinder ? Lot'Size_--- , ..- .20 -- --- <br /> ------------- <br /> Number of living units:__ � . ..._ Number of bedrooms`1R�- - ,- t _ _ -.private <br /> Wale r Supply: Public System land}name ; � Peat � Sand Loam- -_�(,Clay Loam ❑ - -- `L <br /> i , i_ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ [] Y ❑ 1 <br /> Hardpan❑ ; Adobe . EFill Material--__------ <br /> If yes, tYPe = <br /> = 4. 4r, <br /> (Plot plan, showing size of Iot, location of system in•.relation to.wells, buildings,.etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No`Tseptic tank or seepage :pit permitted if public sewer is.available within 200 feet] <br /> F <br /> PA!!KAGE TREATMENT [ ] --SEPTIC TANK'---[,:4-�i.� 4size--- - ----- # '-- r"t;-- 4"---Liquid Depth -- <br /> i <br /> _ - �� No Compartments-.:--- •� .-... --���=_----'TYPe �.� - Matarialo=t.,� �- ,` p z�e <br /> f { ; <br /> _ D' tance,to nearest; Well..:.___i 5_-�.._...--- ":.:'Fopndation,..l0-------- =----Prop. Line --------- - ------- --- <br /> a ;; r; t _ <br /> LEACHING LINE [ No. of Lihes._._ --- ---. Length-of each line ,..?LC2_..- __-- Total Length..,..� .- p <br /> D' Bax-cr.- -Type Filter Alateria epth Filfier Material --_-- 1 .. ------------------------ rn <br /> i, ! ) .�v P' t 299�r `„ <br /> to nearest: Well_ 7_. ._-.Foundation -- roperty Line -; ------------------------------ <br /> 'Distance � <br /> ' __ Rock Fi-led Yes >�ro ❑ <br /> SEEPAGE PITji ' [ Depth..Z�---;- D'a`m ter ... Number_ ? m . <br /> Water Table`Depth "1 -: ---- ---- -- Rock Size: '' Q <br /> --------------- <br /> H -- Foundation .." +' Pro Line-.. <br /> - -- <br /> Distance'to nearest: Well::----='-- -- --------•----- --- s P. ---- <br /> w i ------------------ <br /> REI <br /> AIR/ADDITION (Prev. Sanitation`Permit#_:.-- -_ - ----------- <br /> bate... <br /> = <br /> D to .. --�-- --- <br /> i Septic Tank (Specify.Requirements)—- : t ------------- --------- --------------------------- --------- -- -----. --- -- -------- <br /> r <br /> Disposal Field (Specify,Requirements)-------- '------ ------`-- ----- --------------------------- <br /> ------ - ------- <br /> 1i =_ _ ; <br /> ., <br /> --------------- n : = <br /> _ = ------------- ------ ---- ----- - - <br /> ---- ---------------------------------- -- <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 accordance with San Joaquin Counry� <br /> ► Ordinances, Stat Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> H <br /> "ILrtify that in the perfoir nance'cf,the work for which this permit is issued, I shall not employ any person in such monnerjas <br /> to become subj t t orkma�'s mpeasation laws .of California." . <br /> Signed / --- .-------- ---_ e' <br /> I ,.. . Title -------------- --------------------------- <br /> . Owner <br /> By -- ----- I <br /> ----------------- -'------------=----------------- -------------- --- <br /> (If other than'`•owner) <br /> FOR PART ENT USE ONLY <br /> i H _ <br /> ---DATE..---- -- - = 7 <br /> APPLICATION ACCEPTED: BY'- ------ - ---------- -- ------- ----------------- f <br /> DIVISION OF LAND NUMBER:-:----- ----------,-:-- :-_------------ -------- ---`----------.---------- -- ------------- E ------------ <br /> D <br /> ADDITIONALCOMMENTS----------------------------------------------.---------- ------------ ---='----- =-------:--------------------------------------------------­_--------------------------- <br /> ----------------------- ------------------------------------------ ---- <br /> --------------- -------------- ---------- -- - <br /> 4L. -' __ ___ ______ _ ___________ _._._._...._. ----------------------------------------------- <br /> ---- <br /> __ .._____.. - V ____..-.----..______.... --_--- <br /> 1 __-•-_---------•__ <br /> - ...... ....... . V_z <br /> --•-_. -•--• --• _____•_•_••--__....__--...___...-•___-•- _ _ _-- __- __LLt i � �. ................................ _____.__....-.-.. ` 7` Date { fna Ins ection b =P Y -� �_� = <br /> sa <br /> Fas.aie» REV, 7/76 sm <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br />