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..OR OFFICE USE: n <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMII� ' <br /> (Complete in Triplicate) Permit <br /> ...........................__.. .-......_............. <br /> ............................ <br /> -----•-------....-.... - -��...- Date Issued./L--,$0:7-e K-�.�-..- This Permit Expires 1 Year From Date 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 rdinance No'. 549 and exist ng Rules and Regulations: <br /> JOB ADDRESS/LOCATION L o.. .. . .. ......�� / � GIL4.� -----..CEN US TRACT-------_.---_ _ . ...__ <br /> Owners Name .. - G, G, ,, ,�, r�I>LK1� _ .. S hone . _. .... <br /> P <br /> Address ..... _.. <br /> Contractor's Name.-- -_._.License # ....�...,.J '� <..... <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial Trail r Court ❑ <br /> Motel C] Other_.. ... --_____....-- � <br /> Number of living units: . ...........Number of bedrooms----..... Garbage Grinder............Lot ize......../I /o?_�1-.ti------ - .. _. <br /> Water Supply: Public System and name . ....... .. ................ .. - ............... ...... .............._...--...._ ..............Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material If yes, type.. ..................... <br /> (Plot plan, showing size of lot, location of systemin relation to wells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTAL;ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) . �J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size / C C <br /> �-5.��.................. .... .Liquid Depth..-..�.... _ .......0 <br /> Capacity,M 010.......Type .�. -Material G........No. Compartments.._......--_.............. <br /> Distance to nearest: Well.......... <br /> Foundation.....- <br /> .�.... .-__.- ..... r <br /> J - ..-. . . ..Prop. Line.._.+r._.....-- <br /> LEACHING LINE No. of Lines ......_------Length o'(/��eqch line .- lr.Q--_----.--. Total Length .............. �C <br /> 'D' Box Type Filter MaterialSFilter Material_ -...-. ./ _ NC <br /> 7 - , <br /> Distance to nearest: Well --- `................Foundation._-s ---- ------._.-._..Property Line.......`;'.--. ......_.-.._...... <br /> SEEPAGE PIT [ ] Depth_ _.. . . -Diameter......_...... ....Number__. .......................... Rock Filled Yes ❑ No f1� <br /> WaterTable Depth------------------------. ...........--...........Rock Size..... _................ .. .................... <br /> Distance to nearest: Well.. -----------...-..__......... .........Foundation................ .. ......Prop. Line...................-....... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#................. ...........___ _ ............Date_..........._.-_................. .-.......) <br /> SepticTank (Specify Requirements)-.__ .. _..-...__...................._..... ..............................................I..__. . ---..-_....----.....----.. - --------- <br /> DisposalField (Specify Requirements) ._................. .............. ..........._....-------------------------------------- ---. __..------- .......................-._-........ <br /> ......-..._...................-_-------------------;_.-............................................ ---------.................................. -.-.....-...._. .................. .......... ............. <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 /> signature certifies the following: <br /> "I certify th in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become sub ct o WorlSm�n's ca�m�ensation laws of California." <br /> Signed.. . c 1 .... `jj/ ..Owner /J <br /> By -- .... :C.! C 7.C/.r� (.:� _ Title_.- . <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY yy <br /> APPLICATION ACCEPTED BY.._-....._ .. . __..._. ................._....-.-..---- -DATE .P <br /> DIVISION OF LAND NUMBER .. ........... .. DATE................... <br /> ...... <br /> ADDITIONAL COMMENTS .................. ..... . _._..._.--._. ........ <br /> -..._..... .............. .... . ..............._........ .. .. .................... .. ._....--................. ..................... ...................------ <br /> _........ ...... . ........... .. .. _..._... ............... .. .._ .............-................ ..... - ----------------........................................-... ....... <br /> ------------ ...................._...-._ _- ... . . - _-. ................................__ <br /> ........... . ................. ..... .. .. ...... <br /> Final Inspection by:. _._... .-. ..Date...,..-/./ . -_........ ..... <br /> -. _..... ._......... ....... .......... .......__........--------- -'---_.._ -.- .7. <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6$21677 REV. 7176 3M <br />