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4 <br /> FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No._ e7 -O <br /> (Complete in Triplicate) <br /> - ------------- ----------- ------------------------ <br /> Date Issued_'--3a".7J <br /> ___- This Per_mitit Expires, I. Ye_ar_FromJDateJIssued - Y---e- . <br /> . ..-.-'s r�. <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 Ordinance No. 549 and existing Rules and Regulations: <br /> , ��� � ---------CENSUS TRACT.-. �XQ�-i- <br /> --. <br /> NJOB ADDRESS/LOCATIO . <br /> ii _ -o Phone----------.---- --------------. - <br /> Owner's Name-. l-! T' ---, &I>a yJ?�A[T- Q----------- - - <br /> f� � --� <br /> Address.--- -------°--- --_ t_pt- }.l'JQ�--._ ..x:2.21,----' .City S{�5� ���F� <br /> �'� <br /> ` .. one.- <br /> Contractor s Name____ r r , -. �-��./�-'-��¢--��-�5 ����-•°----- -License i <br /> Ph d <br /> t k e3� .., 5 1 <br /> Installation wdl serve: Resldenee Apartment House❑ Commercial E] TrailehtCourt [_1 <br /> Motel ❑ :Other --- :'------------- <br /> ----------- gd <br /> Ember of Irvin unit------- ------ -Number.of,b <br /> Nu g edrooms__ -____ Garbage.Grinder __ - ____Lot Size_ <br /> t <br /> Water Supply- Public it •� <br /> pp Y= System a d namee'� - . :_ <br /> _ _ - rive e <br /> Character of soil to a depth of 3 feet: Sand ❑ 'Silt 0 'Clay E] Peat Sandy Loam ❑ C1dy Loam J�( <br /> - - . <br /> Hardpan ❑ ;IF Adobe Fill Material._..__:.__ I es, e-------------------p------ ---, <br /> Y type <br /> i(°Plat plan, showing size of(Jlot,'locati nl of system in relation to wells, buildings, etc.,must be laced on re`erse side.) , <br /> NEW INSTALLATION:I' (Nd:septictahk or seepage ,pit permitted if public is available within 200 feet,) # <br /> ' SEPTIC TANK Size_ -------------Liquid DeR1h._4 lr-----=-- 6 <br /> PACKAGE TREATMI=NI 11' <br /> { <. <br /> Jcrit .yl Typeal No.•Com <br /> artments�---f_�---- ------------ <br /> GMateri i <br /> Distance.to nearest: Well.-_t------------- ---------- ------Foundation Prop. Li '_ <br /> J► e <br /> t - <br /> --------------- <br /> --- [-Total Le <br /> ea h line <br /> LEACHING LINE No. ofLines.I ;:- "::-7=�ehof <br /> s► ` <br /> i ? 77 <br /> p' B J� TYpe Filter Material- e� __Depth Filter Material---1-+�------------------------- ------------------------- <br /> -D' <br /> --------- ------ -- <br /> F Dista o nearest: Well E----- -- undation_- Y .. . - Property Line <br /> IT <br /> I �� <br /> SEEPAGE PIT Dep't�h-- ✓� �LDti6rriete - ---s.r-Number _ ----------------- <br /> 4 <br /> ---- - - - Rock Filled <br /> , ..., :.... - <br /> Yes No ❑ <br /> A . <br /> WatE:�' Tfb°le De .th_��- -�., . .� <br /> Rock Si. <br /> - -- <br /> Distance to nearest:Well_.- -'.__- : _-- - <br /> r �W- <br /> -----------I------Foundatiori --� --� Prop. Line---- ----- , <br /> I =----- <br /> k+ -----.Date-------------:------------------ } <br /> EE <br /> REPAIR/ADDITION (Prev. Sanitation Permit#-.;-.--==--"-=i-,�� ---- �. <br /> --------------------------------- <br /> - <br /> - --------------- --- <br /> Septic <br /> - <br /> ecify <br /> Disposal FieldP(Sp(Specify Require_ments)----.-`-- - _ ------------------ ----- ------------- \'ti .. .� <br /> ---------------- <br /> E ------------------------- -------- --- ---------------. . ----------_ ---- -, -:;.-. -. ; <br /> --- ---- -- - <br /> d ' ` ` -' a <br /> (Draw existing andequired addtion onrev rse's'de) <br /> I hereby, certify that 1 ave prepared this application and that the work will. be.done in accordance with San Joaquin County <br /> Ordinances,�I�State—Lawsand--Roles and Regulations of,the San Joaquin Local Health district. Home owner or licensed agents <br /> T <br /> signature certifies the following: <br /> "I certify that in the performance of the .work for'iivhich this permit is issued, I shall 'not employ any person in such manner as <br /> to becornAL subject orkman's Co ensation: ws of California." . . <br /> Signed-- � : <br /> -------------------------- <br /> ' --- Title- <br /> By -- ----- <br /> (If other tli'an"owner) 1p <br /> FOR'DEPARTMENT,USE ONLY, _., <br /> DATE <br /> APPLICATION ACCEPTED BY-------------- <br /> - <br /> - <br /> i DIVISION OF LAND NUMBER --------------------------- ------=--"'-`--- .� - `�' ._ _- DATE.. <br /> �. <br /> ADDITIONAL COMMENTS -------------- ---- - -----.-------- -- <br /> c ----------------------------, <br /> --------------------------------- ------------------------- <br /> ----- <br /> - <br /> Date <br /> b <br /> -- -- --- - <br /> Final-ins ection <br /> p Y-------- --- <br /> EH 13 24 SAN JOAQUIN OCAL HEALTH DISTRICT f&5 21677 REV. 7/76 3M <br />