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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit __ ______ -------------- -------------------- - ----------- Date ----------- ----- --'-•-------------------------------- This Permit Expires 1 Year From Date Issued , - t Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ___ E ~ __ _ JOB ADDRESS/LOCATION. - '- C ''€c' n Owner's Name t:.--- --- y = " • .CEN Phone - f/ SU ".__ ------------- -g— . 5 S'-R6 94 Address -------------- ---------- --------Cid' % � - ` - Contractor's Name-- :. ----- -- ---"-� License 7t� one — .. 4, ❑, p = 0 en iTrailer Court P 7 h Installation will serve: r Residence Apartment House Commercial .. . _... r Motel❑ Other----- . a Number of livingfunits: ,C -.. Nurriber.of.bedrooms' Garbage Grinder----- ------Lot Size--- Water Supply;PuKhc System and name ________ ______ _ /'----- :f_ Private ----- Character of soil to a depth of 3 feet Sand1gr Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ i Hard an Ado e Fill Material ' If es, type P , ❑ . ❑ - Y YP ----- ------------------- ------ ,.(Plot plan, showing size 'of lot, location of system in'relat.ion to wells;buildings,°etc. must be;placed on reverse side.) U) NEIN�INSTALLATION ;(No septic tank 'or seepage pit permitted if;'public sewer is available within 200 feet,] l ;.PAGKAGETREATMENT 1•]'";'SEPTICTANK-"[ .. r Fize:--_��rJ��-S��-_7-- �-� .Liquid Depth: '- t Capacity (�.0-- .:Type / _ _Mate ial._�-i7Y�-�� a No�Compartmen#s, _ ' = Distance,to_rearest: Well.,"' � _.;.'. . .: Founr�a on:_* L�. Prop..Line._ �_.�___. LEACHING LINE , i [ �G;_ [ No. of Line :: ... Length of each line , --- ---.Total Length-------X�r ------ ---- - Dista ox_.[_._._.: Type Filter.Material°�6?0-- Depth Filter.Material_.__-._!G� 'r D' B nce to nearest; Well ,._ o-u-ndation---: ___x� Property'Line" ----------- Ar SEEPAGE PIT .[ ] Depth-----------------Diameter --_. -----------Number . Rock Filled Yes ❑ ''No z i Water Table Depth ----------'~--�`------.Rock Size _ Distance to #. y nearest:,�� . �---(:---__ "-----'Foundb_t;ion._-_-.-.---=___ ,. 4 ,C -- ---------------- --- . .n. e-��~,4--------. --------`-- - ? s= x ---------REPAIR ADDITION Prev: Sanitation Permit# Date. Septic Tank S eclf Re uirements ----------------- ---------- -_--- ---------- Disposal, ------------------------------------------------ ----=` Qis osal, Field (Specify Requirements), - --------------------=- -- --- .___________________________„______ ; =Y - 7 _ ________________--__- ------------------ _ _ _ . z -. -! (Draw existi-n and re wired.addition on reverse side} i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 Ordinances, State Laws; and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "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 to becom blect to .Wor man's. Compensation laws of California." Signed = @J -' ------ Owner �_. - BY--------=-------------------= C / � ----------------- ---Title--- ------ -------------- ------ ------ i f h( ter than owner) f < FOR DEPARTMENT USE ONLY - _ w, APPLICATION ACCEPTED BY_ DIVISION OF LAND NUMBER - -- ------------- -- ` = :: = .DATE - - -'` a ADDITIONAL COMMENTS = - -------------"----- ------ ------ --------------------- ------------------ ------------ ----- ------------------------- ------------------------- ---- --------' ___ ----------------- IE .- ------ --- ------------ -------------- EH - - Final Inspection by:--: - ---- -------------------------------------- --------------- 7 ------------- 7V -------------------------- =----------Date �)-�2 �---- EH 13 24 SAN J AQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M /' 4