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FOR OFFICE USE: _ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------- ---------------- --- [Complete in Triplicate] w Permit No. -- --------------------------------------------------------- Date issued___ __�7 ------------------------------------------ _ This Permit Expires 1 Year From Date Issued 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: JOB ADDRESS [ i } ! ~ , ��j}}� i LOCATIs. _ + ._.it` '�F ..- CENSUS TRACT 4 : ------------------ I - -- Owner's Name _ - - ---- ------------ -------- - -Phone__9-. �-_-6- 40Y Address_____________ /q i ._.____ . .__- G, d C ____ RLc'City---_--___---__- ..__.._ _ ._____.__ _. ______________________ 4 _. ...,., .-F�- �. l:. - . _ _�.� -, .zip. 4 Contractor's Name------- , L , Z.�b- = 4 _ Installation will serve: r Residence Apartment House.❑ Commercial ❑j Trailer Courfi I Motel ❑. Other {------------ 7==- =-- - [ k t . Number of living units:----' _._ _______Number of.bedr.00ms:._ Garb inder_.__------lot-Size.__=._ / age Cyr f -- Water Supply: Public System rind'name------.-----'---- --------=------ --------------------------- ---------------------------------------------------.- ---- ---=- =----------------Private ❑ r Character of soil-to a depth of 3 feet: > Sand ❑ Silt❑ _ClayE] _Peat❑,Sandy.Loam ❑ =Clay.Loarn 2 F Hardpan ❑ Adobe Fill Material.___ If yes, typeY. ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placedio`n reverse.side.) 44116 a NEW INSTALLATION: .(No septic tank'or seepage pit permitted:if.public sewer is available witliii ll 441 ..Feet,) PACKAGI: TREATMENT [ ] SEPTIC TANK rN. .�_-' --------------- �Y ['] ! Size __�Liquyd Depth --- ---- Ca acit �.. .Type--------- Material.==- --.--_ _. f_No. Compartmerits.17 r oti S _ -------------- ------- Distance - - P y n Foundation Pro' t r Distance to neorest:,Well-!._ -__ i + p (Line------------------------- LEACHING -LEACHING LINE [ ] No. of Lines:: Length of each ling-------------------------'-- Total Lengt -::--i--------------------------------- r # 'D' Box. : Type Filter Material ------ -----.'.-----Depth Filter Material--------------------- - lA Det Fit --- Distance•to nearest: Well_ _______ ___ --------------._ -------Pro yerty LiMe_T�� _��..__ __ SEEPAGE PIT ( ] Depth____, __ Diameter_.'__ Number _ Rock Filled Yes ❑ No Water Table Dep#h __ Y� ' _.Rock Size'_ i i_K '---------- - '?� _. J3 _ - ---- - v Distance to nearest: Well-- .�� ___ Fouridation .� 41_.Prop. Line____ REPAIR/ADDITION (Prey:Sanitati' Pe it#_____________ :._:_._Date _ F ' } l ti - _ Septic Tank (Specify Requiremenfis)-------- -- '4!,- P _ BM J �2Q, - . ; i I � t � � y � �/�� 'V Disposal Field(Specify Requirements):---- ;-- --- - �_.�_-_ _ - __-- --_ �yP._'CQ ---------- -- - --=-----'- --------- - I ! - ---------- .I -------- - r.. . .i: -- ¢"� -;-- ----� - --� - { (Draw existing and required addition on reverse side) I hereby certify that�I have prepared this application and thpt the work will be done,,in acco cicincei v✓ith San 'Joaquin County Ordinances, State Laws, and Rules and 1.Regulations -of' the San?Joaquin Local Wecilth-Darrictt Home owner or licensed agents signature certifies the following: , I "I certify that in the performance of'tlie work for which th'i3.permit is issued,,,) shall.not.employ any person in such manner as to I ---�- ---- ----I 's p . Califrnia.'�a=s�t t�i ;-.�C< ��i '� !' t Sighed me subject to Workman s__Com ensation;..lciws_of... 1 i� f. 1 9 i BY - -- ------ --- t ' T - , � I other than owrier) ------ � � � .y � $ j FOR DEPARTM NT USE ONLY APPLICATION ACCEPTED BY-- ------- -fir``---------------DATE.------- ----- DIVISION OF LAND NUMBER,- ------- ------------------ ADDITIONAL COMMENT__ � DATE______________ ' _o�tltt--._.1 ----------------------7 ---------------------------- --------- -------------------- -------------- ---------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- I ------------------- ------------ ------ ------ ---------- --- ------ _-Final"Inspection-by:---- - - ---------------------Date------- _ , - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M