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FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> y (Complete in Triplicate) Permit No. __7 <br /> ---------------------"---------- ---"--------------"---"- /lU'_CCff <br /> r--__ <br /> -•-•----------------------------------------------------- This Permit Expires 1 Year From Date Issued 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 /> II / { [ R <br /> JOB ADDRESS/LOCATION 1 _ -----------=------"----- ---- ----"--- ---- CENSUS TRACT <br /> Owner's Name =----------- ---- <br /> - <br /> --- ------ -- <br /> ------------- <br /> C�, p Ph Op <br /> Address = " ' "" - --- '"------ City.-�" '"-( .azj f"o �iP ff , !- <br /> Contractor's Name - a"-Z'("-----'`----.-i--:--- -.BTI!'J•----- ---------- <br /> --------------License #-----'S�-- ----Phone_V447F6D_7-----"-- <br /> Installation will serve: Residence [ Apartment House ❑ Commercial E] Trailer Court ❑ s <br /> i Motel ❑ Other------------------------------------ -------- <br /> Number <br /> -----Number of living units:-------- ------Number of bedrooms=-'?:�777.Garbage Grinder------- ----Lot.Size-- - dV <br /> Water Supply: Public System and'narne----------- <br /> ------ ------------ <br /> - _ Private <br /> --------:.--,� ------- <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ : Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> A, Hardpan Q "Adobe ' Fill Material-. _ If es e__------- _---_:_ i <br /> Y ,fi'P --"-- <br /> I (Plot plan, showing size of lot„location of4 sysfem in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: ;(No;septic' tank''or' seepage 'pit•permitted ifpublic sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size"------------------- -___1--------------------------- ----Liquid Depth.--- �. <br /> W <br /> Capacity::, :_ _.'TYpe= M"aterial------------------- --.-'No:-Compartments:===__- -'------------------ <br /> r, earest: Well--------------- -------Foundation--: _ -'` `= Pro Line -------- <br /> LEACHING <br /> LEACHING LINE [ ]" No. f f.Lines �-----'_-____ __- - '�__ � <br /> Length of each lme. ri�-._ Tota F'.,Length._� F_ t <br /> t D' Box Filter-4 awl" - Depth File Mat rial__ _ -"-- ----ri <br /> _ <br /> � [ <br /> a Distance to nearest: Well-4; _.. <br /> -------- Foundation-------_ ----- ”Property Line----_---_- ---±-_-. <br /> SEEPAGE PI <br /> I �E } Dept h�-... - Diamefl ".�., Number-------------------------- _ F ,,,;.Rock Filled Yes ❑ No E] <br /> T <br /> • Water Table Depth ---Rock Size------ --------- ------ ------------ <br /> i <br /> r - <br /> Disfance to nearest: We ---------------------,"---"-.Foundation-- ------- <br /> Prop:-Lin <br /> REPAIR/ADDITION (Prev. Sanitation Permit# ----_:-----.- ::-:-:Date_---_: ------------ <br /> ` ---`__ --------- <br /> Septic Tank (Specify <br /> -------"Septic.Tank.(Specify Requirements)-----------------------"--: --- --- i <br /> 7 --------_=--------------1-_------------ .. <br /> Disposal Field(Specify Requirements) QZ, ------------ <br /> S__\ lo.t.�[__- • � ) <br /> 7�u <br /> --"- ----------------- - - .-- - s - <br /> --=-'---- k [ <br /> s <br /> I' # (Draw existing and required addition on reverse side)': i E j <br /> I hereby certify that I have prepared lhiis.pp"izction-and-that-th-e-work-will-be-done-in~accordance,,••withj Saris 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: y ' <br /> "I certify that in the pei-formance Wthe Work for which thispermit 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 /> I - L/ . - wn <br /> erO <br /> By ----" --- O. ---------------- --Title <br /> f <br /> -- <br /> A <br /> f <br /> ------------------ ---------------- <br /> i (If ofher than owner) <br /> t FOR`DEPARTME.NT U5E ONLY., <br /> APPLICATION ACCEPTED: BY- ---------------------------------4--=�_ <br /> DATE . `O-_ _ _ ---------- <br /> DIVISION OF LAND NUMBER ------ ._ - ""------------- "------------ - D TE.- - <br /> ADDITIONAL COMMENTS == ~- r--�- - --zC••-�w.4 - ---�, �7, +-SS, �,,-- ,cRr ,--X ,.�-tom ' <br /> ------------ <br /> ---------------------------------------------------=-------- ------=`-=------------------ -- ----------------------"--- ---------"------------------- ---------"--------- <br /> ---------•--"----------- <br /> --------'------ ------ --- <br /> -------- - ---- -------------- -- <br /> ' -------------------- <br /> '` CIS--I- ___�- . �—" m <br /> ------------"-------------- Date.. = ` � t`��=---"-------- <br /> Final -inspection by --- <br />} <br /> EH �s sa SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7176 3M <br />