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r FOR OFFICE USE: <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> { Permit No. <br /> --------- --------------------------- <br /> (Complete in Triplicate) <br /> ------------------------------- <br /> ----------------- Date Issued_,/.- <br /> 5 ` : --- ------- __ This Permit Expires 1 Year From Date Issued <br /> � 9 <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 application'is made in complipnce with,County C}rdinance Noi�4,and�,ex_'rstin RuJ,esarid_ReguJatioias;_ — <br /> - n�._-GENSIJS TRACT.-- --•-�-r__-----v---- <br /> r <br /> JOB ADDRESS LO T10N _- Q <br /> `�r `��! 4 i - --•-- - Phone_t� . <br /> gf > art"... -----��_� -c-__-•ti } -- ----------- .. <br /> Owner's Named-- _ - -- -- - A <br /> .- . <br /> Address Z1:1 f .13 3 4 9 --- --- ----------------------- ------City - ----------- ---- _ _ <br /> . � � �� Zip ;.. . - <br /> �,`. ?t1; License # -7:3—Phone. <br /> d <br /> Contractors Ngnrte` _. - +f{>P!2��+j ` , <br /> �"� . s P ��� -- ❑j , er Court ❑ ' <br /> Instcillati niliwssrve: �R�sidence A artment House Commeraal t" <br /> ty <br /> Motel t�-{-----Other--------------- <br /> , �,�.� -_--.---- <br /> Number of living units:__;" Number of bedrooms..-.--------Garbage Grinde.r... _,------ ot� -----. -- <br /> --- <br /> ��;:._ K , 0 - ------ <br /> Water Supply: Public SysYern.and name'-------------- ------------------------------ ---- ---------.-.----- ------------------- <br /> Private <br /> �. t 0 <br /> Character of soil to;a depth,of 3 feet. Sand ❑ Silt❑ may ❑ Peat ❑ Sandy foam �f Clay Lo'a ❑ <br /> 14 .Hardpan ❑ Adobe ❑ Fill Material-- --..-----if yes, type-------s-"- <br /> (Plot plan, showing size of lot, location of system in relation`to-wells„buildings,etc. Must be placed ori reverse sidef0 <br /> r t - <br /> NEW INSTALLATION: (No septic tank oe ge:ptittedif"public sewer is available within 200 feet,] t N <br /> I Size- -= ^------------------------,--Liquid Depth/---- ----------------- ` <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] �} 4-,r,% "A <br /> Capacity.0- .�� Type------------- ------Matarial �lU ? __No. Compartments.-- ----- =--------------- «J <br /> i W <br /> Distance to nearest: Well._,.- C�,-i-----=- - --- -=-=-------Fours'dation---���'--1---------_---Prop Line_..F.- -- -=---------- <br /> LEACHING LINE [ ] No. of Lines-- .Length of each.line.--- :. :. Total L ngth -_ '7 a---------------------- <br /> - = <br /> Type Ca <br /> 'D' Box---�----:.--T a Filter -•--- = �-----,De, , -Fiiter Mate rig l.-----�9-�-=---- -------------- -----.-.-------- -- <br /> t me <br /> . r <br /> -------------------- <br /> Distances to nearest: Well "f i .�-- �`Fa•n�atipn����{' `�i` Property L” �C�..- -�--------- <br /> N ---- <br /> . . s „ <br /> SEEPAGE P17 [ ] Depth".�_ -"____Diameter. . umber.-_ :.�... I w.l Rock Filled Yes ❑ No <br /> ' y <br /> 4/0 ] <br /> ----------------= Rock Size Y �i t <br /> Water Table Depth"""-__....""-_."�-_ <br /> Distance to nearest:Well..... Z'...__.---_............. .Foi�ndation...���------------- Prop. Line--16( _..`� "" <br /> REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date------------------------------------------- ------------------------------------------------- ) <br /> Septic Tank (Specify Requirements)------------------------------- - <br /> ------ ------- <br /> Disposal Field (Specify Requirements) 1� °----------------------•�- /ytiYvi y /-0------ -- ---- <br /> �4 r------- ------ -------------------------------------------------- ------------------------=--- <br /> . <br /> _S r <br /> = , - -----�-- ---------- �a--- - t <br /> (Draw existing and required addition on reverse side) <br /> r 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 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 subject to Workman's Compensation laws of California." _ <br /> Signed--- - -------------- <br /> ..... Owner <br /> - - -. <br /> ------. fihtt ... -"---- <br /> Y-- " <br /> (If other than owner) <br /> /n' FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY"__.___..- -_"- - _----.DATE------------ = <br /> DIVISION OF LAND NUMBER ----------------------- DATE. <br /> ADDITIONAL COMMENTS-----=-------- ------------- ----------------------- -------------------- <br /> s ------------------------------------------------------ <br /> 17 <br /> ------------------------------------------------- <br /> / "" -_ _..----- - _ ............................••------------------_------..."__...-___..."__._...___ _•�� -------- <br /> -...---------------------- <br /> _ .... _ ----- <br /> Final•Inspection by= I/lf ----------- •--------------------------------------------------------- pate--- <br /> EH 13 24 SAN AQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M <br />