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FOR OFFICE USE: FOR OFFICE USE: <br /> „PPLICATION FOR SANITATION PERMIT , <br /> ...................................... ................ <br /> (Complete in Triplicate) Permit No.......7h.".9/2 <br /> ....----........................................ Date Issued. <br /> .................•...,.,....._.._.. This Permit Expires 1 Yeor From Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described.16 <br /> This application is made in compliance with County Ordinance Md. 549ynd existing*Rvle5,and Regulations: <br /> el <br /> -- � 5 ]_Je <br /> __._CENSUPShTRACT...... <br /> JOB <br /> RACT.....JOB ADDRESS/LOCATION. --•-Owner's Name.... % . <br /> Address..t�- ..... .. ......... ...-............ <br /> p <br /> 7 7 W r Ci ��9.C�:...------•---------....!.Zip..l.S3.<.4�......... <br /> - _. .�/... L............ _....... - ......... - ._.... tyT <br /> ^�1 T '� c, op <br /> Contrador'sName.`' •. �.:1.�`lOr./!J r.S .............License #--- /t7S��I .Phone._D..G9....3...../...._. <br /> loh«I yy�� iTTT���yiii T c/1.. .. . <br /> Installation will serve: Rlsidence)g A ati tment ouse ❑ Commercial ❑ Trailer Court J] <br /> Motel ❑ Other...... <br /> Number of living units:_.. ......... of bedrooms..3.....Garbage Grinder........... Lot Size..../..-I-L:.,-� +��'.._.i.......... . <br /> Water Supply: Public System and nome..:............._...............,...--...........--........------ .. . . . . -----...—.:.:.:......-..................Private $l <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ CloyE]- Peat.[-] Sandy Loom ❑-.- Clay Loam K <br /> 'Hardpan E] Adobe.❑ -, Fill Material............If yes, type.,....................... <br /> (Plot 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 withifi 200 feet,) <br /> PACKAGE TREATMENT [ ] , SEPTIC TANK J Size..����!P•�...............................Li quid Depth.......................... <br /> CapaSity/_9_1r_('-Type.......................Materiol. ...NO. Compartments........1[.................... <br /> Distance to nearest: Well.....(D Q. --- foucqn�dation—:.. _�— ..Prop. Line..---T,5 .......... <br /> LEACHING LINE [ ] No. of Lines..-......,�.................Length'of each [in;..........1.q...........:-.Total Length ...A-79........................ <br /> ��! <br /> 'D' Box..Ai..'.Type Filter Material/iyt.......... ..�Depth Filter Material... 9-.-.................................................... <br /> Distance to nearest: Well....&?!..............Foundation----.3.d.1....--...--.Property Line . .......................... <br /> SEEPAGE PIT ( ] Depth---...........:.Diameter....:...............Nv er------ ----- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth.. .......... - ---- . . -..Rock Size.... ................ .......................... <br /> REPAIR/ADDITION (Prev. !atance to nffation Peam t#Well:.:.........::....... ... ... .. .......F undaTion...` ..�..-...Prop. Line........................... <br /> ....... <br /> �` ate, -- .......... <br /> ..... . . .............. <br /> Septic Tank (Specify Requirementsl.-----.--�----- --- . ..... .. ........- - <br /> �� <br /> Disposal Field (Specify Requirementsl.,. .... .. . - ----- - .............................................-......................... <br /> ........................................................... • : .............. .. ..........---......I............... ................................ <br /> 1 <br /> -:-•- ,.. .. ........._.... ............ .............................-.............................................................. <br /> [Draw a sting and required a tion 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 /> 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 that 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 s t Work n't Compenscr o la}yc o�,�Californlc-" <br /> Signed., r..:-.. �� � ..-./t....�...(.�-'..,. ...Cnvner <br /> By_........................... .......:..............................::................. .:.........Title............ ........_............ ....... .......................... <br /> I (If. other than owner) + <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY... ... :..... DATE...3 - ............. . . <br /> iDIVISION OF LAND NUMBER..... .... .......:.............................:-:......,.......................................DATE.............................................. <br /> ADDITIONALCOMMENTS.......... ...._...........-'- ... ............................ .......... . ---........_.._-..............-......._............:....,...... ................... <br /> .................. ................ ...::..:..............----•---:....._...._......................I.....-------....... ......... .............................- ...._..................... . ... . . <br /> ..................------- ----- ......... --- .......... .......... .....................---- .......................... . ----------- .................................................._...... <br /> . <br /> ...-......:...............................................................-.,.........---- .............................................--.......................... ................................ - <br /> Final Inspection b Date............................................... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 216 2Ev. me oM <br />