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FOR OFFICE USE: FOR OFFIU' USE: <br /> - APPLICATION FOR SANITATION 'PERMIT <br /> Permit <br /> ------- --------- .............. <br /> Na.�-g-�--�•�-2- � <br /> - (Complete in Triplicate) <br /> ----------------------­.................. -•..----- Date lssued_.�.�.�.5-` <br /> „ ?� <br /> _,-„ ,,--,--•--------------- .----------- This Permit Expires 1 Year from bate 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 r na ce No. 549 and existing les and Regulations: <br /> JOB ADDRESS/LOCATION.,-- - -Q...-. __---- CENSUS TRACT- <br /> yy,� y�®� <br /> Owner's Name f' --- --Phone. I�. ._l.- <br /> .�s',�j - - ��i�/�Z, - .... ......... . - - � .. <br /> Address IgG4 .. .. City . ... n Zip <br /> r <br /> Contractor's Name--------w . r --- ---------------- -----...License #_..3 -b/- .Phone... <br /> Installation will serve: Residence ❑ Apartment House ❑ ommercial ❑ Trailer Court ❑ <br /> Motel ❑ Other-. - .- <br /> Number of living units:..-.-.C-:------Number of bedrooms-_-.=?---Garbage Grinder------------Lot Size.___..-�- <br /> Water Supply: Public System and name........................ . _-.-_Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loa�1,E] Clay <br /> /Loam <br /> �❑� <br /> Hardpan ❑ Adobe ❑ Fill Material.. --_. ... If yes, type------- <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.( <br /> NEW INSTALLATION: (No septic tank or seepage pit permittedifpublic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( Size. .._7K--$ _X- ----------------------- ------Liquid Depth.._:_7-.-------- <br /> jMaterial_ ,,�� -------No. Compartments.--.__._: •--- <br /> Capacity..4 --...TYPe-��t-��l- �v_��`"`__._. <br /> ... ............foundation--/00 - _..-.- -- --.Prop. Line.---- Q <br /> • Distance to nearest: Well__..___.----- .- - / € <br /> LEACHING <br /> LINE [N - No. of Lines.-. --- : ---- <br /> Length of each line... --� <�--.-.-.. Tata! Length _. -)- ----__--- <br /> 4 <br /> I � � <br /> D' Box-7-.. M __ . _ fp � l� <br /> or <br /> Distance to nearest: Well-5Z............. <br /> Foundation.. .. ---Property Line---1.... . ............ <br /> n j r . <br /> S [ „/ --- ---- Rock Filled Yes [�No <br /> MU-A `7 {fie th-- Q.....---Diameter_X/_&.__ Number.... <br /> f O..3 <br /> _ .Rock Size...--- c..� - ---------- - ---- <br /> Wafer Table Depth--------------- La--0..- ----. --------------••-- - - � <br /> / r Line. <br /> Distance to nearest; Well.-. -- _ . ...._---Foundation._.tp(� . - ...Prop. <br /> REPAIR/ADDITION (Prev. Sanitation Permit#...._---_............... ........ ------Date............----......... ......... --------- <br /> Septic Tank (Specify Requirements)--...... ........ ------------------- ...... -------------•---- ------••---------- - --------- :-----. - <br /> Disposal Field (Specify Requirements). .-------- ,--- ------------ -- ---” <br /> --- --------- --------------- ------------------------ <br /> F ------------------- <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 /> s signature certifies the following: <br /> "I certify that in f performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> ! to become sub[e t t W kma s C mpens onlaws of California." <br /> k " .._ ....FC4-� . <br /> Signed........ . .....- -..--- .... .K --- _. Owner <br /> k BY- - - ------.._ -�- <br /> ._. itle----- ----------------------------- <br /> (1f other than owner) <br /> f R_ <br /> ART ENT USE ONLY <br /> APPLICATION ACCEPTED BY. 0 __...............DATE ._ <br /> zs=.. . ._.... <br /> DIVISION OF LAND NUMBER --------- #----------- ------- ......... - -------------------- ----------- <br /> ----... --.DATE --- --- ----- - ------ -.. <br /> I ADDITIONAL COMMENTS...... ......--.... - ..... _..... <br /> ...... ... .......... .................... <br /> -------- ------------... <br /> ------------ <br /> _... - .. <br /> D <br /> Final Inspettlon b ��,•+/� ✓ ,... <br /> y:.... V <br /> EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT Fay 21877 REV. 7/75 3M <br />