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rOk OFFICE US'E: � FOk OFFICE USE: <br /> _NPLICATION FOR SANITATION PERMIT ' <br /> .................................. (Complete in Triplicate) �� -52Z <br /> Permit No----................... <br /> Date Issued.--V/ <br /> ..................................................... This Permit Expires t Year From Date Issued <br /> kpplication is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> s application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> OB ADDRESS/LOCATION -..- �Q� ..........-.CENSUS TRACT..................... <br /> vner's Name.-- ----_._-- - -- - .- .. .-. . . ......-.. - . - . ..Phone-.��/....�9S8y. <br /> ........ .. ... <br /> ..(dress................ ....--__.. S 'b �.Gl/ //�.. Ci - .- .___._.... Zi ... <br /> :ontractor's Name. <br /> _....--- . --.-........_...._-.........License #.. .,J-9.��..._Phone..yP--s��-`/�.._. <br /> Itallation will serve: Residence ❑ Apartment House ❑ Commercials',_frail r Court w❑ <br /> Motel ❑ Other-_ _.............. ---------------------1 <br /> .'umber of living units:...... ........ Number of bedrooms..-...--- Garbage Grinder............Lot Size.-G . .t...-.--._.....-__ -- <br /> .,ater Supply: Public System and name.-_...-......-..............---...._....._..__............ -------------............__........_.-.-......_--_----.-..Private <br /> ;horacter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam p <br /> Hardpan ❑ Adobe V Fill Material__..- .._If yes, type-..._---------------------__. <br /> rot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> •'�W INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �1 <br /> �kCKAGE TREATMENT SEPTIC TANK Size....s13.)ery.............. .........Liquid Depth_'P .'­--- <br /> Capacity.. .........TypeDle.4z. MoterialG ^< ....._...� <br /> . __...No.-... Compartments...... Z . �y.�i <br /> Distance to nearest: Well /_Dd., Foundation_J.40 . .....Prop. Line 5 r <br /> // ...t.....__........ r <br /> MACHING LINE No, of Lines . ..J...................Length of each line-----jl114...].........--....Total Length .................... <br /> 5 Depth Filter Material-..--.Ar.~ <br /> 'D' Box..... .. ..Type Filter Material..._.![ ... p .................. .. ........... <br /> Distance to nearest: Well../Q.l)......t......Foundation.--JA0.................Property Line...rT--../.-(V ►............. <br /> � r pp <br /> SEEPAGE PIT [✓r Depth.-._.. .Diameter.. 33.--- ._.._Number_.../._._................. r Rock Filled Yes (r No <br /> r / <br /> Water Table Depth......../.................................... ....Rock Size...z;2X.3----..-........ -------------- <br /> Distance to nearest: ....... <br /> .............---------Foundation...... .__.Prop, Line.-��......_-. -...... <br /> aEPAIR/ADDITION (Prev. Sanitation Permit#-.--...-..-..----------------- ------_.........Date............--- ......... <br /> _:ptic Tank (Specify Requirements)......._. .......... --------------..........._..-....__...----------------------............._._.---..__....._._........._._......_.-. <br /> Disposal Field (Specify Requirements). ................,. ................................_..............................j-------.._...---_ - ----- ...-- _....-.-...... <br /> _.............. .. ..._.....-...-....._._..._... . ...-.......................................----- .............. --............._......._....... . . .............- ....... ...... <br /> -.. ........... . ....................----------------- ........................................... .......... - ..... ........-._...................... <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> tirdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the fq[aowing: <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 /> • o become subject or man on. laws of California." <br /> Owner <br /> Sgned..... ...... . . . ...... <br /> iy................. <br /> ...... ..---.......... - sd1".Title - .. .. <br /> ......-._...... _ __ _ <br /> _ ...._.....__... <br /> (If other than ownerl <br /> FO DEPA NT U ONLY <br /> APPLICATION ACCEPTED BY........ . . .. .__... - - _.... ._..-...-........... -------........DATE ..._.-.... -I$ .7............_........ <br /> DIVISION OF LAND NUMBER_...----.-..__................. ........... ... ....---.......................- -------....._..DAT E-...._............... <br /> ......_. ...._.-._..-.. <br /> ADDITIONALCOMMENTS- ._-.................... ......... ......_.....--...............--...... ...... . ........_._........_. .......................:._....._. .. ....... <br /> ------........------ ---- .. -- --- ----.............---_ ................ .-........................ ......... <br /> ..... <br /> ..... <br /> ....... <br /> ....... <br /> -.-... _ - --- -------- .-.......... ._...... ........ <br /> ... . . ............ -.................. ............... .............. .. --... -- .......... --... .. .........-`- ............ .................................... .. ....._........ <br /> ' <br /> 'incl inspecion by:.-.........� k � - <br /> 'D1jOW.D <br /> � ................... <br /> 21677 REV. ]/IA 3M <br /> EH 13 24 AQUN L AH TH <br />