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FOR OFFICE USE: � l FOR OFFICE USE: <br /> J� APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No---___.__.__�:- <br /> ----------------- - -------- ---------------------- <br /> Date Issued_Y______`7-7 <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 and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ' <br /> j t ,C :_tJOB ADDRESS/LOCATION.: :�,�i�DL .! -V- _s,r --CENSUS TRACT -------------- -- -- j <br /> f Owner's Name 1 _ -- - -- --N� S `7 `r' - ' _Phone__5�V7_-- <br /> Address-----=--------- /�D_ ,� 1 ��'lof/:5/A�__ '..City .�'T cTvy = ' Zip <br /> Contractor's Name______________�_e/�_4���15�`f._�ont��:��rt_cr,__-_ License #=Z^���� Phone'_�t����%6a� <br /> esidence� Apartment House ❑ Commercial ❑ :Trailer Court ❑ #Installation wilE serve: - R - <br /> ❑ :: -- ---f--=-- ----= i <br /> �..._ . Motel .O#Fier i 4 <br /> Number of living units:- 'Ii------Nurriber.of_bedrro�o_m_s: . -Garbdg'e Grinder___-__..____Lot Size �-V-te_�?9C'__ _ __________ <br /> Water Sup pl'y Public System_and:namerf -- --- -- -- --- --- - -- ------ --- ---- ---- -- ------Private�$� <br /> Chara-cfee-r-of-soil#o as depth of 3 feet: Sand-O-----Si1 Lj"; Clay ❑ Peat ❑ Sandy Loam rl Clay Loam <br /> ` .Hardp'an Adobe Fill Material_____`-_____If yes, typeF--__--__- - <br /> i _FF <br /> (Plot plan, showinig.size_af_lC;4jocation of system�i relation elation to'wells, buildings,.etc. must be:placed on!reverse side.) + <br /> NEW INSTALLATION: "(No i-septic sank`or seepage .pli permitted if public sewer is available within 200 feet,] <br /> } i <br /> PACKAGE TREATMENT"' SEPTIC TANK ' [") t Size__ :___ ---------- - -'*-""'l i uid De th '___s I <br /> [ ] == <br /> # ' ? :q I t <br /> ----- I Ip .. <br /> 1 Ca acit ;-'--:-'-- ----T e Material -__-r ---E:__-_-'-----No. Coin ar4 ents F- <br /> -- ,Foundation- -- .,_..L.•%___•._ <br /> 44, <br /> f . ¢¢ -- <br /> �� "'�,, •- _.DI sanceito n�earest�+WelE;-... -�-- � p ,:_Prop. Line-------------'---------- <br /> - ' <br /> LEACHING LINE`,-1-H-----No-of;Li�es..- ,7--Length-of' each line. -_- ----- .,_:_.Total.,Length.--- �-------------- ---- --------- <br /> QBox_-:_._______Type Filter Material:__ '_ ___ eoth" it#er.Materlal ___ ____ _________ <br /> Distance t crest: Well _ ___Founda`tion __ � .__.Property Line , _ _____ __ _._ ___- _ <br /> r __ _ NL <br /> SEEPAGE PIT :[ ] Depth__-+ ~__? Diameter-� ---------Number ------------------- .,. Rock Filled Yes ❑ No <br /> Water Table.Depth --------------- "�_ -'----------------------- Rock Size`' ; <br /> <., '- <br /> I Distance to nearest: Well----------'----------' -------------'---:Foundation--- ---`------ Prop, Line.----_--------------___--- <br /> REPAIR/ADDITION (Prev:Sanitation Permit#____________________.____.'__.__________:_::___:Date____-._______-___- .- --_--1 <br /> -. i <br /> Septic Tank (Specify Requirements)-----ig = =- = '�' a <br /> Disposal Field (Specify Requirements)- Q --r.,-- - - { <br /> ----`-------------------------------- --------- ---------- --o q_ 4 .2-� ------ ----- ------- -- --------------------'------ �T <br /> - - ----------- ----- -------------------------=----------------------------------------------------- <br /> (Draw existing and required addition onr,everlT side) ; <br /> I hereby certify that 1 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�Locd health District. Home owner or, licensed agents <br /> signature certifies the following: r' <br /> "I certify that in thatorkma <br /> rmance of the work for which this permit is issued, I�shall not employ any person in such manner as J <br /> `. <br /> to.become subject 's Com ensation aws.-of California.'.'. . .. i <br /> Signed--_,-----c- f_ ----- _ Owner <br /> BY = 5 ------------ ---Title_._ - --- - - ---. <br /> t <br /> i 4 <br /> (If other than <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- - ------ ------ ------------ -------------=--' f---j------------------i'---'DATE...-----3-~~-3- -------------- <br /> DIVISION OF LAND NUMBER. ---- -- ------------------ ----------------- -------- DATE.------------------------ --------- <br /> ADDITIONNAL COMMENTS--- ___ <br /> -- --- -- - ------ <br /> --------- .- <br /> . fi-------- bH <br /> i 1 <br /> ? ---------------------------------------------------- ------------------- <br /> Final Inspection-by ----------" -----------------------------' ----Hate <br /> eH 13 24 � SAN/JOAQUIN LOCAL HEALTH DISTRICT F&s sibs REV. Ana 3M <br />