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FOR OFFICE USE: FOR OFFICE USE: : APPLICATION FOR SANITATION PERMITo �'.. Permit No----7-7--: (Complete in Triplicate) 41 Z? ----- Date Issued.._ . -------- This Permit Expires 1 Year From Date Issued j 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: � � i JOB ADDRESS/LOCATION.LG�// - f �------G��'-��-� -- -'-- - CENSUS TRACT-.-.__:- i /v�nr( �`� p( - "a- -------------- ------------------- - --- Owner's Name._ Phone_ c•5. wU_ l7 - Zi Address- -- .�+l�� - City p., , #�r s �` cl�. ---- -- - _:Licensees Phone ! Contractor's Name-- --__ .... - - Installation will serve: t Residence € Apartment House.❑ Commercial ❑ Trailer Court ❑ r : Motel Other-= - = I Number of living.units:__ ---- Number.i f bedroo43�__ _. _-Garbage Grinder- --Lot Size -- ---------- --------------- ------------ ` ' P rivat e -Water Supply: Public Systmandname--------- - ----- . - Character of soil to a depth of 3 feet: : Sand ❑ Silt❑ Clay D4 Peat❑ Sandy Loam ❑ Clay Loam ❑ _ . . _ {I Hardpan ❑ Adobe ❑ Fill Material-____.__-___If yes, type------------------------------- k -------------------- ----- ---= F {Plot plan, showing size of lot, location of_sysfem in relation to wells, buildings, etc. must be placed on reerse side.} NEW INSTALLATION: (No septic t a nk'or_seepage pit permitted if publi sewer ism available within 200 feet,) /f i f, } f l PACKAGE TREATMENT 11' SEPTIC TANK `[ ] . .,� -- Size , _x e- /_l---------- ---------------Liquid' Depth._ ------------------m . i P y I - f ---------1- ----------No. Compartments . Ca acit {: � • TYpe � Mate�'ia -- Foundation_/�� ----- ------Prop. Line ��1 ,=- ------- €€€ Distance.to nearest: Well--- +-- -- LEACHING LINE; [,l Na, of Lines------ ------ - -----. Length of each lin®.--- . ------ ---.-.-.-Total Length..-- -------- --- --- 1�I D' Box-. -__.Type Filter Material-��a'A;,Lepth Filter Material.._. � -- -- t I. Distance to nearest: Welled - _.Foundation '_._.Property Line__:------------- SEEPAGE PIT l t i j Rock Filled ,Yes No ❑ i IT �. th � ti--- -Diameter. �__ Number[�] �P - ----------- ----------------- t--------------------- Rock Size Distance to nearest: V+Ief .f--_-- - ...... ------Foundation--------------------------Pr1p, Line--------------------------- i'eci4it-. Table Depth..._.-__ _._ � I # y, I Date ' REPAIR/ADDITION (Prev.. Sanitation Permit#_ .:-_�_.._ ------------� ----------.--_--- { it Septic Tank (Specify Requirem ents)_•...:....:::.: ..........j_,_ - -: = == --------------'------------ E ------------------ t - Disposal Field(Specify Requirements)-.-n`'- -:------'--- =, --------------------------------------------- ---'----------- ---- ---------------------•---=------------------- ------------------- ---- --------------- :-------- ---- ------•----- ---- -- ------------------- - - ---- .4�c•- -•ate.___ {Draw_ex sting an required addition on reverse side) ' / _ „� I hereby certify that I have prepared his application a4'that the work will be done in accordance with San Joaquin-County Ordinances, State Laws, and Rules/and-Regulations,tofrthe San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: � f "I certify that irk the performan eof #tk he wor 'fo°r'which this permit is` issued, I shall not employ any pgrson in such n+annerM1as to become subject to or an s,,Compensation-la-w o California." r Signed ! ; ner Ow t �.= --- -: T :_. ---------- i. --- ---------- - ------------------- =`"'�- ------------ ---'.Title (!f other than owner) t + _ .- .• ,FOR DEPARTMENT USE ONLY: --------.- � -=--DATE- -�=�-�-��-IJ---- ---- ------ APPLICATION ACCEPTED BY_ `�-'---- ------ 1 DIVISION OF LAND NUMBER.. � :: _ -- � .E_._ a �..a_-�A _-«. -- -: . ADDITIONAL tCOMMENTS------------:_--.'_-------------------------------------------- - ------------ ______________________________________________________ ----------------------- ---- --- _______ _ _________ _ ________________________________._-.._.-__----_-_-__._--._-------_______. ----..__.__-_---.--____--y.__ ._ .._ FinalInspection b ------•------------------- ----------- ----------- ----------- --Date -T_1�I- --� ------ -- -----�--=-- -.. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M