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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ----------------------------------------------------- Permit No-�.16..E61 _ [Complete in Triplicate) -------------------------------- 6 --- Date Issued_�.� �.� _------______------------------------------------ .-- This Permit Expires 1 Year From Date Issued ! Application is hereby made to the San Joaquin Local Health District for a permit to construct and.install the work herein described. t This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: s _ JOB-AD DRESS/LOCATION_ �w-!1�1 =- ==C . _. ---_- '=_ _._.- _-: CENSUS TRACT - ' d,o� � � `crF__ -- ----- Owner s Name /� '= �G = ... -------- ----- � Phone "' --------- - w Address -------- --------, ------ --_ -- ------ tY -------- Zi r �..._.. Contractor's Name_"-.__.� -�/ti Ti�c�r� _ -`------ --------- ----- --- -- -- License #d� ° • .,�� Ph ne_ � ��'1 ' Installation will,serve: Residence . Apartment House ❑ Commercial E] Trailer Court ❑ � !_ I �. ,i_ .Motel ❑ Other-- = -. I Number of,living_units:5a: _._ _____Number of bedrooms_-_.Garbage Grinder-------._.__Lot,.Size-_.__ ____'a�4._3�--------------------- Water Supply: Public System and name-.------.-- -=-- --=- ' -----.--: .-- ----- -�--------- -- --Private N i Character of soil to a depth.of 3 feet: •T Sand b❑' Silt t] aClay ❑ Peat❑ _ Sandy Loam ❑ Clay Loam ' — v ` p ❑ 0 eriai�' '""""f yes;iYPe ---------------- - (Piot plan, showing size of lot, location of sysGe _in.relotion to wells, bo ildings,'etc, must be placed'on reverse side.) NEW INSTALLATION: (N6-.septic ton-Vor seepage pit permitted if public sewer is available within 200 feet,) i PACKAGE TREATMENT, [ ] 'SEPTIC TANK[�] -"�- Size_..- '��'= .6 't-------''-----Liquid Depth _- Y_- -- ----- ,� I Capacity_ c _ =----Type._ �� _C0-9.S_r_Mater ial_- --------� '---='--:---No. Compartments_ -- ' . Line/ --;------- Prop __Dista _- LEACHING LINE. [F] No.of Lines_ k__. Len th of each lile._,_Y . Q__ � ___.Total length.- -__ -. '-- �--' _ x .� T r 1 --- _ - Distance to nearest: We11_;�j�__ Z -1 -.._Foundation__________________ wA _ D' Box__: fiype Filter Material__ ::.p___�-Depth Filter Material-. i r , ---.Property Line, t ° SEEPAGE PIT [ ] - Water Table DeDthmeter------ . --- ------- -----_-- ----- `Filled 'Yes.❑ No ❑ R Rock Size-:--------------------------------------------- ---------------- 7 - Number Roc i'`---- I, Distprice to nearest; Weld_'-_ t ''-•----. -----.Foundation-- ----------------------`Prop. Line- ---------- _______.':___-__ -- REPAIR/ADDITION (Preva Sanitation Pe�rm�it#. ---_ _ - --=-=-------=-Date----- -- ---- --------------------_ ..___-__---- l Septic Tank (Specify Requirements). - - = - - ------- ----- ---- Disposal.Field (Specify Requiremdntl_�_!- ---------- = -- - i E -- ---- ------ --------------- -----y----------- ------ . ------- ---------------------- ; ------- --------------------------- ---- ---------------------------------------- -- I-----;_-_---_------------ ---------- -------------: � - - - - -------------- -------------- ---------------- --------- -------------------- ----------- ' # IlDraw exisfng and required taddition an reverse side) ' I hereby certify that I have prepared ih`is application and-that the ywork will be done in accordance with Son Joaquin- County Ordinances, State Laws; ctAd Rules and-Regulations,of?kthe,San Joaquin Local,Health District. Home owner or,licensed agents signature certifies the following: "I certify thavin the performance of 41 a work for which this permit is issued; I shallr%n, employ any person in such manner as to become subject, to Workman's- Compensation laws of-California.? [ � ?J - Signed =------ - -----------------------------------_ .. _ . .. . ' •� -- _ towner � � { g �- Ti - --------------------- ----------- ------- --- ---------- t i ° to -- r (If other than owner) ! c :FOR DEPA TME NT'USE"ONLY f APPICATION ACCEPTED.. Y� -----------� ------- - �---- - --DATE -- �--- - -�- -------- [ c DIVISION OF LAND NUMBER` - - .DATE- ------------------ -------------- 4 ADDITIONALCOMMENTS �K -- - ------- -----------'---- ----------- -- ------------------------------ ------ ------------!--------------------------- --- t _.�.." --------------------- ------------------------ --------------------------------- ,- .. - •-- .____-.-.._-_---_.-_.---__-________-_.---_-_----- _-_-______--.--,_�-__-.-._.--_---__•_-----_.---_____-______. __-___. --._-__ ---.z_ _____ _______+______________ ___•__.____.___.___.______ __- ____ ----------------------------------------- __ - - -------- ------------- ---------- -- - -----------__ ------__ -------------------------- N _._--.--_---_'Date.Final Inspection b EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 FEV. 7%76 3m