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_ FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT a Permit No---- ---------- ------- ----------- ----------------- -------- --------- --- ---- (Complete ------------------------- (Complete in Triplicate) !1 ------------------------------- Date Issued...y---7� This Permit Expires 1 Year From Date Issued 7 1 >•--------------- --------------------------- -------- -- Application is hereby made to the San Joaquin Local Health District for a permitfto construct and install the work herein described. This application is made in compliance with County ordinance No. 549 amend existing Rules and Regulations: f ---CENSUS TRACT---------------- --------- ----- -- ---------------- ---------- ------ - JOB ADDRESS/LOCATIO ' P Owner's Name'-- --------- -- -- -- =- -- -- ., ��1 I Ad-0dres's--- --- --.. --��' '�2�� _ �.. •�G _ .__- - /� ---- --- - -city------`�� -- --------------ne _.-i_ ---r -.�«--� -- -- -- - �T' ° Contractor's Name - __�' -t � - - -- --- -4 - --- _ . L'++cense ,#��_ �-�� ------- Ph ,_. -Y. .. .Corhmer6al ❑' Trailer Court ❑ - Installation will, serve: Residence � Apartment Mouse ❑ ; rte_ ,- Motel_❑�, Other.:._:_ . -- - f ,ry -------- --- - - --- i Number,of living units:--------- ------Number of bedroo is- C Garbage.Grinder. Lot Size l I -- - ----- Prwate : ! l Water Supply: Public 5 stem and name - - CI L ❑ Y : _ ' } eat Sandy Loam ❑ ay Loom f t Character of soil to a depth of 3 feet; Sand ❑ :Sift❑ i :Clay ❑ : P - Fill Materici If es, type---- --------- --- 4. x Hardpan Adobe ❑ Yi {Plot plan, showing 'size sof lot, location of system in relation to wells, buildings, etc. must be placed,or"reverse side.} I s NEW INSTALLATION: (No- se tic tank or seepage Pit permitted if public sewer is available within 200 feet,} p PACKAGE TREATMENT SEPTIC TANK...[,],. Size '_-- - = -� - i Liquid Depth ._ . Co tments_k--�--------------------- a - o r ype + ----- - Material mpa i p y.._..:..... Q. ..Distance .to.near-est:'Well"�--- --- -------- -- •------------=--- Foundation r�P�: L 5 --P Line i 'Total Len th.. ! Y; LEACHING LINE ,[;l f each line --:-- - - g No. of Lines � ---�-- r'_ _- ---.Length fi D' Box--..-' �` _ Type Filter Material o'!. Depth Filter Material-� ._ _ --- ;%---- 1. � . . _� .. ' Property -Line-r-4 T Distanceto nearest: Wella .. ou ., N .. .__ --- -- ( }` Rock Filled Yes❑ o SEEPAGE PIT T[ j Depth- ..._ --- Diameter. ...-. .. ...; Roc ------------- ----- ' Number � ' ' - k 4 . Water Table:Depth----------= -------- = - '. Size:.+ a Distarice'to`nedrest: Well- _ _-- ----- Pr me-- Foundation op -} I t ate- , REPAIR/ADDITION (Prev.-Sanitation Permit#---------------------------- -- --- -- -- -- -I- t -------- --SepSeptic tic Tank (Specify Requirements)-- -- -- -------------- €! -- Disposal Field (Specify Requirements}.____-.- - ---------- - D= --------------------- - --------------- ------------------------ ------------------- -: -_----------- ----- ------------------------------------------------------ - �- ( raw existing and required addition on reverse'side) I hereby certify that I have prepared?this-Opplication and that the work will be done in accordance with San Joaquin County es'and and Regulations of the San Joaquin Local Health District, Home owner or licensed agents Ordinances,' State Laws, and Rul signature certifies the following: v s } "I certify that in the performance i . . of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California.'.. Owner _ � •- - Sig ned- --------- I (if other than.owner) ' i FOR"DEPAP-TMEPT USE ONLY F APPLICATION ACCEPTED IiY.. 7 l ��-` F --------------------------------DATE ---- ' ------DATE---------------------------------------------- - -- DIVISION OF LAND NUMBER------------------------------------------ --------- ------------ --------- ADDITIONAL COMMENTS _ - . - _ - ------ --------=---------- ---------- ------------ - ----- --- --- ---------- ---- --- -- -- ------------ ------- ---------------------- - - -------------------------------- -------- ---- ------------------------------------------------- -- --------------_ -- ---_----- - -------- --------- ---- - - - r - -- -------------------------------------------------- - Date �--- -- - Final Inspection b &S 21677 REV. 7/76" 1 - EH 13 24 JJJ SAN OAQUIN LOCAL HEALTH DISTRICT i