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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �� •_ ��i Permit No----- --_--- i ------------------I----------------------------=---------- (Complete in Triplicate) Date Issued------------------ -- ------------------------ ------ ---- ---- This Permit Expires 1 Yoar`From Date Issued Application is hereby made to the San Joaquin Local Health District for hi, rmit to construct and install the work herein described, i pP % This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB AQDRESS/LOCATION , 1Dt� �-. -� !_��G Zj �`�' -----y-- - CENSUS TRACT.,, JOB ' Phone__ -7.--•�c' r3--- <� _ t----- --------- - Owner's Narne.__ -�- - _ . T i ................. ---- ---- ------------- -----�---- --- �--- - ��-- --- --_------ ---=City --- �wc- Zip---Y6-;?.?'� I Address-.- --------... _ - g Car 0.3 Phone- -S Contractor 5 Name___. -__ f�-*-- --1'� �f-�` ` = License #-_3 7,rt/ :.. Instal'iation•wiil serve: Residence [ partment House ❑ Commercial ❑ Trailer Court 3_.._.. - Motel ❑ .., Oilier-- \-----------------` . -- , N umber of living units:-____�i-_-__Number of.bedrooms.__�-`rf-Garlaage Grinder----- =_Lat Size. 5 _ -`-------- - --Private: t { Water Supply: Public System and name________________ _ - - ' e Character of soil to a depth of 3 feet: Sand ❑ .Silt❑ Clay ❑ PQnt❑ Sandy Loam ❑ Clay Loam ... ( Hardpan ❑ ? Adobe;❑ : Fill Material__.___- If Yes type_""_-___----------------- �` . {P1ofi plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avail;ble within 200 feet,) SEPTIC TANK --------------------------- r Size--- -�WY+ I rj �quid Depth PACKAGE TREATMENT [ ] ,Q ,� _ �'•, . Capacityl �Q` SType_AB:.e.�! -t.----._Material=-Yt - ---- ------ Compal tments---------21-------------------- 4_. I i 0 --------.-Foundation-----.>�---- Prop. Line: Distance to nearest: Well --_------- - - a , g l _ -------------------------- 0 -- No. of Lines______ " _ Length of each line""€ Q�' Ttal Length.__.__O- - LEACHING LINE' 11. y� A--- -- -- -teeng_h��ne t � /�,�/ h Filter Material___a ----- -- - -- --- 'D' Box l TYpe Filter Ma .. �..�`7:;"".t::: .. .Depth ,� r •` ,-.- j () I p p Foundation .. -------- -------Pr.operty Line--s�Q-------. Box- ------------- I .Distance to nearest: Well_'/_�__.---+ _ - -- o :, -5----__'"----Number _.__-- ( Rock Filled Yes No ❑ SEEPAGE PIT I ] Depth-�C`-' = Dfiam�ete oo Rock t ize !'-� ! ,. '.. ,., / • F- --( T,.: 4.Foundatlorl___ �d ; // Water Table-De th__-!_= .- i_-____- -------- .Prop. Line__J�-/------- - Distance,to nearest: Wel(-_:, _-7 ---N-- t. � ] ------ --- P.Date--- ---------------------------------------- REPAIR/ADDITION ) (Prev. Sanitation Permit#- _- ----- ------ - i . t - _ ------ ments)=------------- ------- Septic Tank (S(Specify Require = j Disposal Field (Specify Requirements)- .------------.----.._ ---- - r ------------------- -- ------ -- -- -- ---------------------- ------------ ------------------------ j- j = --- ------------------------ - -------- ----------------------------------- --- = --------------------- -------- -------------- (Draw existing and required addition on reverse side) + I hereby certify that I have prepared this application and that the •workwill be-done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of tSa�noaq'umL' oaealth District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of"ahe work for which this permit is.tssued, I shUl :not employ any person in su manner as I to become subject to Workman's Compensation' laws of� California. 11. F Signed------- =--- --------- = ------ _ __"-�.;} Owner " ----- ------- --- Title._C9�-�" .... (if other than owner) 1 . ., r• FOR DEPARTMENT°USE,ONLY ' 'sr --------- -- - - DATE. i APPLICATION ACCEPTED BY -- ••-- ,.� - ----------_ DIVISION OF LAND NUMBER--------- --- - - --------- --- - .--- .��--------- ---------- - ----------- DATE_:----------------- ADDITIONAL COMMENTS-------------------------------------- ----------- c- ------=--- ------------------------------------=------•--------- ---------------------- - -- --_ - - --- ------ -------------- ------------------- - --------------------------------, - - - --- -- a ------------------------------------------- Final -------------------------------- -------- ------- ---' ----- --. - -- � Date -------- Final Ins ection�b - ------- ------ ------------ - ��r-�j----f -- --- p Y=- ---- ..�---�.' - „ ---- --- ---- - -- - -- 111 F&S 21677 REV.7/74 3M EH 13 24 SAN JOAQUI LOCAL HEALTH DISTRICT