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5: • FOR OFFICE USE. -------- ^__-_ ------ APPLICATION FOR SANITATION PERMIT FOR7No.. �k2l ------------------------ -_ ------- [Complete in Triplicate) Permit--------------- ----------- This Pe'rmif'Expires 1 Year From Date Issued Date Is _. _ Application is hereby made to the San Joaquin Local Health District for a per This application is made in compliance with County Ordimit to construct and install the work herein described. Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.__., Owner's Name !� llI 9C^ T Ci � . 14CNSUS T RACT _ . =----------- Address-- ------------ ----- --- ---- Fho . Cit ---------- f-Name--------- r - - -----------zip :------------- ----------------- -------- • . ,..: LicnseInstallation will serve: -------- -----Phone----- .Residence � - t - --------- f wf fii _. armenHo-use❑ Commercial ❑ -Trailer Court.Other__ ; ❑ _: -_.:q: .. Number of living.units:__:__,- ------Number of.bedrooms_� t _ .,' i. ----Garbage Grinder-----_------Lot:Size-_.,._7--[9 Water Supply: Public System and name _-_::____________ ___ --_ - f� y . .. ------ ------------ ------ Character of soil to a de th of 3 feet: Sand ---------------------------------Private p --- -- - -- - ----- -- ❑ Silt❑ ay ❑ � Peat❑ Sandy Loam Hardpan �Adobe ❑ Clay Loam ❑ } ❑ Fill Material_ es, type- (Plot plan, showing size of lot, location of systemin relation to wells, buildings,'etc. must be placed on reverse NEW INSTALLATION: °(No`septic tank or seepage se side.) pit permitted if publicise mer is PACKAGi'�REATMENT [��] SEPTIC TANK available within 200 feet,J ; f 1 Size- - . ------------------- Capacity------ ----- ----TYpe------------- =- -- ----Liquid Depth.------ ----�-------------- Material------ ----------- - No. Compartments------------ , to nearest: Well............ . ----"----- �d ----- -- -- Fo LEACHING LINE U No. of Lines._____ ,- un ation_____________________ Prop. Line-___-_--__ rop Length of each line. = ,., ---- --Total Length .:'D' Box - = -TYPe Filter M -atil__=___- -___-__Depth . Filter.Matenal'_ -._•---_ - --- ------------------ ' .Distance to nearest: Well.y___ ' .„.F --•1` -�-« ---- ---- oundation_'-- -------------------- SEEPAGE PIT .� • � ..... - ....-: { l Depth. -----`---.D;iameter-` - _ ---Number--- - [ R Water Table Depth.'-'--- _-'-- Property in �l : -.. F Ye No'EF . x Rock died Yes -------------' Rock Size--- - s ( Distonce'to nearest: Well-.!-'- ---- - s 3 `Foundation- - Prop. Line------- ------ REPAIR/ADDITION (Prev. Sanitation Permit# � � _ � � Septic Tank �-.Date_ (Specify Requirements)--------- ---------= t Dis posal Field (Specify Requirements)_.._--__-_- 2 ` - - :. - -------- --------------- = ----- ----------------- ----- -- -------' a ---------------------------------------= -------- (Draw =: __ __ (Draw existing and required addition on reverse side) "' z I hereby certify that I have prepared this application and that the work,wilf,be done in accordance with San Joaquin Coun 4 Ordinances, State Laws, and Rules and Regulations of. the San Joaquin L"oval`Health District, Home owner or liven signature certifies the following: sed agents ; "I certify'that in the perforrnance"of the work for which this permit is is g lett lo. Wo m n s. om sued, );shall-not employ any person'in .such manner as to become sub' Pen`tion laws of California.',' E ' Si ned__ I ------ 'owner) -- -- - 'Ow---BY- ------ ----- : -------------- ------- --" . ------ � . d( fotter than oner) FOR DEPARTMENT USE ONLY APPLICAT DIVISIONIOF LAND NUMBER.---- - DATE. ADDITIONAL COMMENTS - �A7E -------------------- ----------------- --------'--,DATE -- ---=--i---- ----- ---------------------- - ------------- --- '==. ---------------- ---------------- --------------------- - _-_ ih l Final Inspection b --- -- ----------- ------- • ----------- - - EH 13 24 ' � --- ---------------�--------- ----- ------�'-Date-- --- ---- ` 42 SAN�JO QUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M