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FOR OFFICE USE: [/�i0 FOR OFFICt: Ubh: <br /> APPLICATION FOR SANITATION PERMIT �$ �g J q <br /> ....... ......... _. ` 1. 0 Permit No. .. - ! <br /> r, (Complete in Triplicate) <br /> . ...................... <br /> •.. .............— .. ....... <br /> Date Issued./.D...:l1--._.?. <br /> ........................................................ 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 andinstallthe work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> .JOB ADDRESS/LOCATI /Y�I7- _ .-. !i�!Af/j �r fp,�,r. - CENSUS TRACT------------------ <br /> (' .�3 ..--------- <br /> Owner's Name.._ CL'P.Ma �..../.�.!.,�. ............................... (.� . . .Phone ..... . ..................... . . <br /> G� .6P . . 8a �. . ...city 5. � . ...... ........ zip. 9.. S o B <br /> �� <br /> >ddress ___ - <br /> Contractor's Name.. --- ---- ...................._-------------I...................License #............................Phone.......:..... • -------- _--- <br /> nstallation will serve: Residence N" Apartment House ❑ Commercial ❑ Trailer Court ❑ <br /> Motel ❑ Other._..... ...............------------_---- <br /> Number of living units;. ....../.....Number of bedrooms....—7 Ga bage Grinder.._........Lot Size-..........2. x 8....-..._.... <br /> Vater Supply: Public System and name..-.... __....(_/e)Q;.. /--- .. ---_.'._.._7...'..............................._.....--------.------_.............Private ❑ <br /> 'Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe rV Fill Material.. _.. ....If yes,type . <br /> . lot 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 or seepage pit permitted if public sewer is available within 200 feet,) - U <br /> 'ACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size........ .................:..._.._--------------------_-Liquid Depth....... ... ..... <br /> capacity.1.2,08.------Type.GOYJ,C1f4Aaterial..........................No. Compartments--------- --_.._.... -- <br /> Distance to nearest: Well.....,/.QA14- ----------- .........Foundation........-- - _.- .... Prop. Line------------ - ----------- <br /> EACHING LINE [ ] No. of Lines_.......................Length of each line..../-1lQ_�.........Total Length _ ` ........ <br /> 'D' Box_./---...Type Filter Material..... ------ --- Depth Filter Material.../.,t� ..............._-_..-............- <br /> Distance to nearest: Well....,..�yi�`Ae/-------Foundation............................Property Line.............. <br /> 'SEEPAGE PIT [ ] Depth.2..S:.�Diameter.. .y„r..l.!? Number.....19-------------- _-.--- Rock Filled Yes [� No ❑ <br /> Water Table Depth . .......--- ... --- -- .....Rock Size................................................ <br /> Distance to nearest: Well-..--&4P.A/-E--- -_----- ------Foundation..........................Prop. Line........................... <br /> REPAIR/ADDITION (Prev. Sanitation Permit#....----------------------.----------------Date................._...----...---.------.-.) <br /> eptic Tank (Specify Requirements)...... ............ -------------------- --------- ----------------------------------_--- ........... -... ................. <br /> disposal Field (Specify Requirements).......... ........... ........... — ............. .. .............-- . . .... ... ................ . ... .... ........... ----- . -- <br /> ....................................................... ......... ........... ................ ....:. . ...................--- _.............--------------------- ----- --- --------- <br /> (Draw existing and required addition on reverse side) <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> )rdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents <br /> signature certifies the following: <br /> '1 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 esu ect to Workman's <br /> /7Compensation laws of California." <br /> Signed--9'_A -- -/ - - --..............---._..... ..Owner <br /> ty-----------------_. ............. .- - -...---- - - -o -_. ...... ......_...-,_..:.......Title_- -�Wl/1 !.._.-..- - _..._.. <br /> � <br /> (ifother than owner) <br /> P09 DEPARfMENT USE ONLY <br /> OPLICATICNJ ACCEPTED BY--...._. -. _.. . ................................ .DATE ....... <br /> DIVISION OF LAND NUMBER _... ry T y -- <br /> f /� +y . DA Q <br /> ADDITIONAL COMMENTS.._ --K!(1 .CLA.. . ...�++..... ... ...... 2 3... <br /> tti4 "� .h7. .V.................. .. .... .------­----------------- . _... <br /> 61!1-----------------T---...----............_.... .... .............-'-----'----'--------'--................-----....------------=--.......----------'-.......-----"------................. ..........----- <br /> . .--. --.. --. .. -.. . . /a zG . <br /> 0 =final Inspeciwn by:.. - ............................. ........ . ........ ........Date---. . . .. res atan aev. rna a. <br /> 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />