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FOR OFFICE USE:
<br /> I APPLICATION FOR SANITATION PERMIT ,r FOR OFFICE USE:
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<br /> (Complete in Triplicate) Permit No._-7 -f/0-y�
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<br /> k ---- .•----- This Permit Expires 1 Year From Date Issued Date Issue
<br /> This --
<br /> Application is hereby made to the San Joaquin Local Health District for per�mitto,construct andtinstal.l,,the-work herein described..
<br /> This application is made in compliance with County Or'drrance No. 54'9 '4existing Rules and Regulations:
<br /> JOB ADDRESS/LOCATION----.,::._-/: - 3 -_............
<br /> -_-. _ . ewOkg A(,,, PC/ {
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<br /> ' 0�-- --- ,--------- -- ---- --- --..,CENSUS TRACT----.-------- - -- ---' -..
<br /> 1. rx I c-��.. `d U '
<br /> Owner's Name ------ - ---- --- �/� -
<br /> 3
<br /> Address-----=---------- --- ----- �� . ,Phone --.- ---- --.----------- -
<br /> ------------- ----- city_ . ,�- �n_/rl
<br /> x y ,-_ l,rY Th d- ��, = a =-------- _
<br /> � � -=-------License #_/6.6 -s`8�---!_.Phone--------------------- �
<br /> Contracfior's Name__;---_-, 1 - � ---- --
<br /> Installation will serve: Residence ® ' Apartment House❑ Commercial ❑ Trailer Court ❑
<br /> ( p Motel
<br /> _ ❑ Other--- --=--------- --------- ---- ---- --==_ . . �- .... �
<br /> Number of
<br /> ---------
<br /> Garbage arba Grindar-------.-_�-Lot Size-------_------
<br /> Water SuppIYrv)Public S.y stem and_narneer-of.bedrooms.-- ----- ---------
<br /> -- -- .- --- -- -
<br /> g
<br /> ------------------- -Prrvate
<br /> Character of soil to a depth of 3 feet: Sand ❑ Silt Ej5s00), jl Peat Sandy Loam ❑ 'Clay Loam ❑ �
<br /> Hardpan ❑ ' Adobe❑ Fill Materia I."--- -.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 r seepage pit permitted if public sewer is available within 200 feet,)
<br /> PACKAGE TREATMENT [ ] SEPTIC TANK- -
<br /> [ j-,
<br /> Size _ - • ---------------Liquid Depth.:------ -------------------
<br /> -Capacity---- .:__ 1': Type -------------
<br /> -:-Material !---------- No. Compartments
<br /> Distance.to nearest:Well--_...-.,�_ ____� ._ f /r
<br /> �_ -_ _. Len t o ea rna..._ ,_�. Prop Line -..
<br /> LEACHING LINE [J No. of Lines. n4 a 'an +
<br /> � -- ' I otai Length ------------------------
<br /> yD Box.-_ •.-:. Type Filter Materia; �°"4. .�h Filter Ntiaterial-. - .--. --
<br /> �. -
<br /> ��i�C 3. i . ---- -- --- -
<br /> Distance to nearest:'Well--------=---------------- --Foundation.:._-_..._____.-__-
<br /> �� '. --------.Property Line---
<br /> SEEPAGE PITbe �
<br /> [ ] , Wateir Table DeDmeter - __ Number - ` _:-n-, Rock Filled Yes ❑ No
<br /> I PthRock ;Sze---- ---------------- --------------------------
<br /> r Disfiance to nearest: Well----------------------
<br /> _1€ -- �„_.Foundation--------------------------Prop. Line----------------- --
<br /> REPAIR/ADDITION (Prev. Sanitation,Permit#- _ - - l_q �1 i
<br /> ------------------------ -- - - !
<br /> Septic Tank (Specify Requirements)...... . . ..... &X
<br /> qfi,_...__.�
<br /> 1 --- --------
<br /> Disposal Field (Specify Requirements)...li,J,� sj � _--,f�pp5 ,
<br /> -----'--------------------
<br /> ---- ----- -----�`�`5►G t� _i!/E' ---/1
<br /> -------- --- ------ -- T SQ,�rv� � ! c e�% ' %7��'l1'�ir
<br /> c
<br /> (Draw existing and required addition on reverse side}: �! C `�
<br /> I hereby-certify that I have prepared this application and that the work will'he,done-in-accordance with San'Joaquin County
<br /> Ordinances, State Laws, and Rules and Regulations of:the San JoaquinLocal'Ffealth District. Horne owner-or:licensed agents
<br /> signature certifies the following:,-
<br /> �.I certify that in the � ..F��.��._._._._
<br /> performance of,the work for which this permit'is issued, I shall not employ-anyl_per'son°in such"manner as
<br /> to become..subject to Workman's Compensation. laws of California."
<br /> Signed
<br /> rg ned- � Avbl
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<br /> Owner
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<br /> itle �'
<br /> than owner). _. l r
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<br /> { FOR DEPARTMENT USE + i
<br /> APPLICATION ACCEPTED BY___. ` � Z
<br /> ,, ,
<br /> = --DATE.--I= Z 7
<br /> DIVISION OF LAND NUMBER----------------------- . . � - -,--- ----
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<br /> -:------- ---- ---- - ----- --- DATE ----- --- ---- -�- -
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<br /> DITIONAL COMMENTS---------------------'-_-----
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<br /> .,.e.�-�-----.-.-�-------
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<br /> Final Inspection-by------ --- `fy f
<br /> 1s 2a SAN JO QUIN LOCAL HEALTH DISTRICT Fas 21677 REV 7176'see
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