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FOR OFFICE{USE: FOR'OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.- 7_--1�T7- --------------------------`------------"---- (Complete in Triplicate) _ Date Issued_, _. 717 r - This Permit Expires 1 Year From Date Issued --"•-------------- ------------------ E Application is hereby made to the San Joaquin Local Health District:for•a per-reit to construct and install the work herein described. — R This application is made m compliance with Co'u`nty Ord nonce No,549'and e) _'This and Regulations: k . - f ' -" ;- -_.CENSUS TRACT--.1" JOB ADDRESS/LOCATION.- �0 ` S�s S-- i Pho ---- ---- ,$ 7�v / '/'�/U/Y�rP Owners Name._. ---- - _ i ---------------- -- -------------------------- Address -------- ---- - -------------- -- _---- C-tY-------- --- l p? j&AI �' ------ --License # K�-.,3 Phone - !- I O Contractor's Name---- ----'�!-�------ ---� .-�---J�- .A ; _.. . 1 F Installation will serve: Residence [$' Apartment House ❑ ICommercial ❑ Trailer Court ❑ l € —Motel ❑� �"Other- _{._s_.> - v Nu##tuber of living units:_............Number of.bedrooms_.��-.---_Garbage Grinde•r_._- Private Water Su ❑ Silt" ! Public S stth of 3 feem and] etname____ --� l EJ Character of soil to a dep : Sand• El "Clay ❑ Peat❑ Sandy Loam • Cla Loam I I 'H El El Adobe F] Fill Material--------- -If yes,type--------------- ---- -- "�- 3 I [Plot pian, showing •size of lot, location of,system in.relaticn to wells, buildings, etc, must be placed on+reverse side.] NEW INSTALLATION:' (No-septic'tarik or seepage :pit perms#ted if public sewer is available within 200 feet,] l V ------------------------------- --------------- iquid Depth. ------------------- PACKAGE TREATMENT' ( ] , SEPTIC TANK ( ] f ' Size--�;--------E.- t ' i.____._________.__ 4 l � . _, _ - -- -'.-- ---No: Compartments_--------------------------- Capacity,__ 5�,� T Type V____ I ti.--_Foundation Prop. Line-i i---- "- Distance to nearest: Well:- ]-- , �� , en th of � i__ Total Length _;.-__ LEACHING LINE ( ]` No. of Lines n g K i each I a ; Depth Filter Nlaterlal_.J -_ ; D' Box--------- �Ype Fi er•Material----= k l p .±e. ., } t N p Line--------- to nearest: Well- tt-"Fou dation Property Li . ;,._.. .:. - ` j- -# °� �`. . Rock Filled Yes ❑ o -- _._ Pro - - . ------------ - SEEPAGE PIT [ ] f Depth Diameter Number_._t } y /'Water Table Depth-------------- F--- -- Rock Size-- _ .r . . = Foundation:''x Prop. Line )y------ ------ s -R Distance to nearest-Wei9 --- .__ r .--- -- -------------- P € REPAIR/ LDITION-(Pr;ev.[Sanitation ermit#-------------=---"--- .Date - , ; ] :i Septic Tank (Specify Requirements] ' t �d 09X-- ---- = - [ 9 -_ ____. ____ -_ Disposal Field (Specify Rebuirements]_:_...__- "Y- - -- - ,� L,r�� - . T.y_ y ----------r------- -- I ----- y ----------- f_o "(Draw- i-s'tirig and require'e addition on reverse side] ' ; k I hereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,• State Laws,' and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents 1 signature certifies the following: "l certify that in tfie performance of`the work'for-which this permit is issued, 1 shall not employ any person in such manner gas to become subject to..Workman's Compensation laws of California.". k f - �i61 "----�� «"------ ------------------ owner Signed ' /7iYl-- Title---- = - -------- ---------- -l o r than.owner) I .. OR DE MERIT USE ONLY DATE.- p _ ..�----= .r_"7- APPLICATION ACCEPTED BY.--= -""-- ----- AT DIVISION OF LAND NUMBER_----=--------- - - ...... ADDITIONAL COMMENTS------------------- - -------------------=--------------- F ----------------- ------ _ _______________.--- __._--_______-_ _------- ____ ________________"______-_-__.____---_._ -_ __-_.---_".___-._-___._ ______-__._ _ ____________ _ ____________________ ____________________________ __ _ ____ -- --------- ------ . - -- fi ----- ---------------- Da to =.- ---•---- r ------------- --- 6 3M Final-Ins ection b s /�z i ..- p Y=-------' '"- --- F&5 21677 REV. 7/7 EH 13 24 _vim SAN JOAQUIN LOCAL HEALTH DISTRICT