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FOR OFFICE USE: d � � : <br /> 3;OFFICE <br /> }P. . 9®• If APPLICATION FOR SANITATION PERMIT FOR OFFICE USE <br /> ------- Permit No..7-�-.p.�' <br /> 7 (Complete in Triplicate) ...... <br /> Date <br /> E •-------------•----------------- -------------------- -- This Permit Expires t Year From Date Issued <br /> I ' <br /> Application is hereby made to.the Son,Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is..mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDR • 1 ,. � v -..;. . <br /> ESS/LOCATION9V:...w(Q747?/"/W f '.r.......... .................. CENSUS TRACT----------- .............. ... <br /> Owner's Name.......5/- _..- 19 1- 5.. 36 /��/ <br /> ..... ­­... . ..................... ................. <br /> Phone----------------- -- <br /> Address. ...........!Fog-_S'iAU�. ... i= Ci GP .!'� Zi" <br /> .-----•;----------------- - city P----------•------------------- <br /> f� l2�2/S/ , ,J <br /> Contractor s Name ! ... = .S-P S........ .. ................ .. . ...License #.1 7`:- ,3...Phone.... �� fa.......... <br /> Installation will serve: Residence- :I-A-pG'rttnen't,Hoise ❑ Commercial ❑ Trailer Court ❑ <br /> Motel [] Other---... ....................: <br /> Number of living units:._- _.—. _.. <br /> -.L......Number of bedroomsGarbage Grinde,r---------...Lot Size:'.'.-_�-�l _ X -�`rr. <br /> ..... . .. <br /> Water Supply: Public System and name......--- --------------------------------------- w ='.1.\----------------------- --------Private <br /> Character of soil to a de >-lardpane❑RTSand Silt Nle erpal...._ . ..If yes, -&San-.y..... ,.-❑ .. y Loam ❑ <br /> p ❑ y ❑ �Peat� _•a,.PSand`-foam Clay is Adobe <br /> {Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed•on reverse side.)-' <br /> NEW INSTALLATION: (No s ptic tank or seepage pit permitted if public sewer is available within 200 feet,) Art <br /> ._S7 <br /> PACKAG; TREATMENT SEPTIC TANK [ e ... ...........(• <br /> . .. ..............Liquid Depth.---,!S------------------n <br /> Capacity.- .ZO.ra `TYPeEC_T__......Material....-Crf/ ---------No. Compartments..-------•- - - ---- y <br /> �... <br /> Distance to nearest: Well.'........-.L + .r-.�f...- .�.Foundation..---.��..�°.........Prop. Line---`- -�-------- <br /> LEACNIIVG LINE [1.]� No: of L nes. ..' .-2 .F 64- <br /> F . .. ..............Length of each line.------------ ------ Total Length . l`3 <br /> __ <br /> ✓.. Type Filter Material SI .:--: Depth Filter Material <br /> ,D' Box .............1. .- <br /> Distpnce to neoresf:"Well:__ Found'ation .. .... ..`�=Property.Line.-.-.-.... - <br /> - - -��---�------ <br /> [r� Depth----�..- _...-Diameter................�..Number---.----------------------..-.-- Rock Filled Yes No <br /> i .. .. ..... ..........Rock Size.----.-3�5�.n.X../ ---- <br /> X�;�X/O - Water-Table�Depth:�:�._::::...�::--'--'------ ---------- ----------- -- <br /> IDITION <br /> Distance to nearest: Well.........._���_....................Foundation..._.��....�'......Prop, tine...,.REPAIR (Prev. Sanitation Permit#----------------------- i...---..--- ............................................... <br /> Septic Tank (Specify Requirements)------ ------ .4 -- -=----------------------- ----- --------=--------- ----------- <br /> Disposal Field (Specify Requirements)................ _ , X • <br /> ---•-•...............•-----------------.._..------------------- -- 1 ... . r <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 County-"-. <br /> Ordinances, State Laws, and Rules,and Regulations of the San Joaquin local Health District. Home owner or licensed agents <br /> signature certifies the following: I <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Sighed..... --- -------- -Owner <br /> By............... .... = .............................--:Title-----...---EST/I.Z.tcc �p <br /> (If other than owner) <br /> JF19R DEPAR1MV4T USE ONLY <br /> APPLICATION ACCEPTED BY....-• DATE ... ............. <br /> DIVISION OF LAND NUMBER................. . DATE.- <br /> ADDITIONALCOMMENTS................................................... ----------- ------ --- -------------------------....-...-.------------....----------------------------------- -- <br /> tJ ' *;° = e --------_- ----------------------------- -- ------------ -- -- .. -- <br /> ..-----•................... ............................... ..........---............... <br /> -- w, - <br /> ---------------------------------------------- ----- . -----------. --..-------- <br /> Firial Inspection by:-----. :. ----- <br /> - - ---------- --------------------Date. ---� . 9.. ........_,............. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 2t677 REV, 7/76-3M <br />