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rOR.OFFICE USE: ' � FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No-----7��T7 <br /> I <br /> -------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued.---.3 <br /> ,F <br /> Application is hereby made tol`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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION„- ��• F ` _,w-----c�7T�111F 1�'/I -..- D! - ..._.._CENSUS <br /> TRACT----------- ----- <br /> ------------ <br /> Owner's <br /> --- -J-- <br /> (^ <br /> Owner's Name c 11g0 --------------- <br /> - -- ----------`--- t ----- ---- --------------------------- <br /> -- ---- ----Phone_,. <br /> Address__ / ' -S? <br /> ---- , ��- ---' = �'CitY .. Zip--- ------------ ---- <br /> } <br /> ll-I <br /> License # <br /> ' <br /> Contractor's Name - - A _., ._ t------ ----- ------ , ?� ----Phone-- ---F - a �l , <br /> 1nstaIlation']wiII serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ f <br /> -MotelcE Other----------- <br /> # + <br /> Number of living units:. L .._I�---Number.of bedrooms_.-__-Garbage Grinder--.'.._...'._.Lot,Size------ .__-__.- - <br /> Water Supply: Public System and name ,` ---------_:.-,:---------- -------- ---'----------------- ------- -- --- [ -------Private <br /> Characterdepth ofp3 feet: Sand [7] Silt[j Clay F] Peat E] Sandy Loam ❑ Clay Loam <br /> - <br /> of'soil to a <br /> Hard an Adobe.0 Fill - <br /> Material_..I.-----If yes, type---------- --------------------- — g <br /> • �i � � t _ <br /> (Plot plan, showing 'size of lot;location of system in.relation to'wells buildings, etc. must be placed on reverse sid.'e.) +� <br /> NEW INSTALLATION: °(Non se tic tank,;or see a e ifd <br /> it if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT- [ ] SEPTIC TANK [:] permitted51 e_ _ �; ---t-- > ------------------Liquid Depth`.;--�---- ----------- <br /> c <br /> Capacity <br /> t P Y �" `TYpe_ 1 _ �l�tater ial F:No. Compartments- <br /> -- - <br /> _ <br /> Distance a to nearest: Well_'__- --- � :_: _t_. ____.'Foundation:_ -_______-_Prop. Line_- (�__�_--_- <br /> LEACHING LI] �� } <br /> NE [ ] No. of Lines----------:-:,.-•_.-----;----,'Length;of.eacli�liria.__'- - -------:.Total Length.----- _` G .----------------- -- <br /> '. i <br /> D' Box . r_--:..Type Filter Material/j _I� Depth Filter Material ----- .�9 __.__ <br /> ' IWell--/",.-.! <br /> ... �. #, - ------ <br /> Distance.to nearest: Well /i `� undation___ ;:-Pr Property Line ce --- _ <br /> --- <br /> - <br /> -__-_-_ _-- Rock Filled YeSEEPAGEPETI Depth _ _. . Diameter '. ----- --- Number __ No <br /> WateiTa 61e.Depth- - - iz - ---- ----- ------ -t ------ <br /> -- -�- `--:- --- oc a ------ ._ <br /> .P,..... �''r 4 <br /> Distant`e:to nearest: Weil- _---:------------ _ !9 .--.Fo undation---------:--.--------'---.Prop. Line--------- ------- <br /> REPAIR ADDITION Preva Sanitotion Permit + p' ' <br /> / ( --------------- ate--- <br /> iM <br /> RequiremIM -------- <br /> Septic Tank (SJecify = _____-Y_. - ---------- '.y' . <br /> - = ::= -- --- <br /> =------- ------ ---- -- ----------Disposal Field Specify Requirements) � <br /> - <br /> ----------------- - IF : , 4 <br /> i � _ `... _ by ..-----------------------------------------_ ____________ _���----------------- <br /> ____._ ._- _ _ _.__ _________-- __._._ ._-_,____-__ _________.__________.. <br /> ----- ---------------------- ----- --- - --- <br /> = = <br /> i;l, T . ------ \ <br /> {D'r,aW�eexfstiin"g an-a requir_ed`acJdition on reverse side) <br /> I hereby certify that.I have pepared this�applicaii'on and that the work will bed e�in accordance with Sa'n Joaquin County 1 <br /> Ordinances, State Laws, and IN Rules :ani—Regulatio"ns of the" San Joaquinl,Local Health Disliric#; Home owner or licensed agents <br /> signature certifies the following "' _ '"`f <br /> I certify that in the performance of the work for which this permit is issued, I shall not emplgy any per-son'.in'such manner as <br /> to become .subject to orkinan's mpensation laws of California." . . . . . : <br /> Signed-=----- -'-- -- - 'Ownar <br /> --- -- - _ - <br /> BYI - ------------ -- ----- ------ Title ------------------ -------- --- <br /> If her tFidn4owrier) <br /> . H 'FOR-DEPARTMENT USE'ONLY ' <br /> APPLICATION ACCEPTED:BYT-I ; = -I-- DATE_. __l =? ' <br /> ------ --- -------------- ------ <br /> DIVISION OF LAND NUMBER: -'" - <br /> - -----------------------------------=------- ----- .-- <br /> -----.DATE ------ --- ------------------ � <br /> ADDITIONAL COMMENTS- l' 'i- ' ------------ --------------------- <br /> ----------------------------------- <br /> ----------------- <br /> - _ <br /> -------------------- <br /> --------------------------- ------ <br /> I ' <br /> ` --------------------------- <br /> - <br /> ------------ _-___- - -------------------------=--------- ------------------Date.. -------- ------- ------- -Final Inspection by EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 7 REV. 7/76 3M <br />