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f <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> 'APPLICATION FOR SANITATION PERMIT <br /> ------------------ -------- 7f- fiG'6 <br /> (Complete in Triplicate) Permit No----------------- ----- <br /> Date Issued_J�,�,-`.7f <br /> - • -------• --•---. . ............ ------- This Permit Expires 1 Year From Date Issued <br /> Fpplication is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application is made in compliance with County Ordinance No. 5,49 and existing Rules.and Regulations: <br /> r,,OB ADDRESS/LOCATION - /��-7Q----- CENSUS TRACT.....-_... <br /> --- <br /> )wner's Name_ ..-Phone.,,. 6�` �17PL <br /> Address--------------- .7Q-- .._ r�°l Gty.-. Zip <br /> -1,� <br /> :ontractor's Name--- <br /> A�� ..-;.:.:ff 'C ------------------License -Phone-.,eW��rfb .--..- <br /> .-installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel r❑ Other............... ..... . ..•---......---------- { <br /> / f <br /> 4umber of living units:-...p--.-.____Number of bedrooms.--vF-...Garbage Grinder-----:--_---Lot Size--.-- __ <br /> Water Supply: Public System and name------------.--------------- - �------------------ -------------- ------- ----------------. ------ - -- ------------------PrivateX <br /> P ❑ ❑ Y ❑ ❑ Y Clay <br /> Loam ❑ <br /> �haracter of sail to a de Hardpan Adobe � Silt <br /> Material__ ._._ .Pelf yes, typend---Loam---- Cla <br /> Jlot plan, show' size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.). <br /> EW INSTALLATION: (No septic tank or seepage pit permitted.,if public sewer is available within 200 feet,) U <br /> PACKAGE TREATMENT [ ] SEPTIC TANK . ' Size OZ -----------4.04010- - <br /> Compartments.------_- ---.. .. <br /> Distance to nearest: Well-__gid -_..._-----------------..........Foundation.... --.Prop, Line--%5... _ <br /> LEACHING LINE Nd. of Line.- Length of each line. d�`y4�. �'"..Total Length ...L-a,4..�--..:- <br /> FF D' Box...4___-....Type Filter Mater ai- �fj1? f .Depth Filter Material__... ................ <br /> Distance to nearest: Wel l_-- ------------------Foundation-----A0---------------Property Line_.-_ _._ <br /> -------------- <br /> )EEPAGE PIT ( Depth__?`- Diameter---33.........-Number-------'3--------------------- Rf Rock Filled Yes ' No El <br /> f <br /> f Water Table Depth------------ ............. -- ----- - -•--- --Rock Size- Y <br /> Distance to nearest: Well-----/66............---------------Foundation.-- 4__............Prop. Line.-.16?.... --... <br /> f�EPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------.------------.Date--------------.--------------_----.----------) <br /> SepticTank (Specify Requirements)...... ............. ------------------- - - -•----- -----------------------..-.-.-..-.----------------------- --------...-------- 1 <br /> isposal field (Specify Requirements)--- ---------- ------ -------- - --------- .............. --- -- ----- <br /> ' I <br /> --- -•------------------------------------------------- -- -------- -------------------------------- -------------------------------------------------------- ------..._------------------.._.._.. ------ 1 <br /> j (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: <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 becom ble t to Workma 's Compensation laws of California." <br /> Signed - -------------------- ----------------------- - ---Owner <br /> ea <br /> F " • it <br /> BY------------ — ..---------------------------- --- . ..-...Title ......... <br /> (If of er than owner) <br /> OR EPARTME SE ONLY `` <br /> APPLICATION ACCEPTED BY ' - "`�' ... . DATE _.._...._. .l. <br /> ['DIVISION OF LAND NUMBER.------. .._--------------------- ----------------F-------- 1 ... ------------- DATE-.._ <br /> ADDITIONAL COMMENTS------------------------ --------------------------------------------- -----------.--- <br /> ------------------------------------- ---------------------------------- ------------------ ....... ---------------------------- ------------------------------------------------------ . -- <br /> FinalInspection b - - - --------------- -------------------------------------------------- --------.Date-..-- - - <br /> r- — — cowl tr+nr11". Ir1!"AI IJrAITW n14ZTDirT F&S 21677 REV. 7/76 3A <br />