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/FOR OFFICE USE: !/ FOR OFFICE USE: <br /> ,•,�/ APPLICATION FOR SANITATION PERMIT <br /> i / ----------------- 1- �+� <br /> j (Complete in Triplicate) Permit No..- - ---�Y <br /> -- 90 <br /> This Permit Expires 1 Year From Date Issued Date Issued_..._- --------- <br /> � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> Thi'i application is made in compliance with County Ordinance No 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATION • ----------- <br /> Owl <br /> ----�----- M.�/�/ .__ <br /> O lner'r Names------ __ <br /> Phone--------- ;.� <br /> . <br /> Address - �.. <br /> r <br /> i• City <br /> Con#rector-s Name _ .�:�. License # __�- <br /> f .. -,� _ : I. ,-AMC( ��4 � � Phone <br /> 1 will:ser-ve Residences" Apartment House.❑ Commer iah❑ Trailer Court❑ <br /> Installation . Motel ❑ Other--± -.-_ _ <br /> -- --- --- <br /> Number of.livingunrts:r-:__. _ _Numloer.of_bedrooms.- =__:Garbage Grinder_.-`Z _Lot.Size :_.__ I <br /> Water Supply: Public System and name--._ ._ Y - <br /> .�C Privates� <br /> = . <br /> Character of soil to a depth of 3 feet; Sa.n4d ❑ Silt❑ Cltir[ Peat ❑ Sandy Loam E] Clay Loam E] <br /> Hardpan ❑ ;�AdobeX• Fill Mdteri�dl�------If yes, type----`- --------------- ----- ` <br /> (Plot plan, shoving size of lot, locat n of=system-in_relatn o wefls;_build�in_gs, etc, must be placed oh reverse side.) <br /> NEW.. INSTALLATION' [No sep�tir-tank�or seepage pit perimitted if public inewer.is available within 200 feet,] <br /> PACKAGE-TREATMENT`[ ]_a SEPTIC TANK '[;�] �-Ss1r -- k Ciquid ' <br /> \ - L qu'd Depth -------------- <br /> --- N <br /> . ".,. Capacityi ' y`>, TYpe �` ' '' tMaterial '_'- "�`.,.�:N(5. Com artments l - 1_�- <br /> ;►�` z istance-Ito nearest: Well------ ------- ----- _--Foundation . Pro . <br /> ; -- p..Line <br /> fCHING LINE No. of Lines-.-------, ---:____::.,e_._.Ltength of each line.- <br /> . `---------.Total Length _4; P- -------------- -- a� I <br /> 'D' Box__ -_Type Filter Material_.- . Depth Filter Materialf���� v I <br /> T/ `l- <br /> Distance to nearest: Well_:_- r foundation-._ P ------------ <br /> �3�� /Q -Property Line •� <br /> SE EPAGE PIT [ 4Depth_o� fl.-Diameter._ -.Number-_----- -- _ ------ Rock Filled Yes No EJ� .. <br /> Water Table Depth (l Rock;Size- <br /> - - <br /> #. Distance to nearest: Well GO!.t` : ---- __Foundation .-_-`a---------------Prop_ Line---- <br /> IL . ------------------ <br /> REP <br /> -__ �__-- __ i <br /> REPAIR/ADDITION (Prey° Sanitation Permit'I_T ____- __1 . 5" '_ 1y <br /> ` ------.Date ----- <br /> c T61< <br /> Dip"los I F' [Specify Requirements) -- -------------I-•----- --- ------=------ --- ------- -------------------- ------ -----=----=--------------- <br /> - - -.- <br /> p.. a{{, field (Specify Re.quirements].= - - : <br /> -------------- <br /> ----- ----- ----------- <br /> i. <br /> --------- ------------------------------ --------- --------------- <br /> (Draw existing and required addition on reverse side[ <br /> N <br /> hereby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin County <br /> ` q <br /> Ordinances, State Laws; and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> Sig nature'certifies the following: r <br /> "I certify that in the performcncii"of fhe work for which this permit is issued, I shall not employ any-person in such manner as <br /> to 6eco6e subject to .Workman's Compensation' laws of California." CLl.rFiJCE'S gEFTIC �, <br /> SEWER SERVICE <br /> S9 ned-t----- = i. -Owner 263 So. Oro Stc chtc;� Calif. 95205 <br /> - ---. <br /> Y = <br /> ] � 2i)� i <br /> $ - -- =Title = --------------------------Lic.X26.1.177 <br /> t7 - t <br /> (If other than .owner v� M <br /> F "EPAXTMENT VSE"LY <br /> i <br /> APPLICATION ACCEPTED BY ------ ------- ----- ---- -- --1-� -------------- --- -----DATE..----- ---- - <br /> DIVISION OF LAND NUMBER.-L ----- --`-:----------'------<----- DATE. ------- -----------.-- ----- ------- <br /> ADDITIONAL COMMENTS._ _.-., __- � 'Lor !� <br /> ------------------------------- <br /> ----------------------------------------------------------•-------- ----------- -------- <br /> i -------------------------------- <br /> --- ------------------------ -- - - <br /> ------- - <br /> Final Inspection-by----:______- ✓---------- ------------------------------------------ • - � <br /> - - - - ---------- -- - -- ------------Date------- �- <br /> EH is za SAN JOAQUIN LOCAL HEALTH DISTRICT r-as 21677 REV, 7176 3M <br />