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n II FOR OFFICE USE: FOR OFFICE USE- FOR SANITATION PERMIT - -------------- ------------------------------ Permit No.----7 (Complete in Triplicate) � ------------------------------- -- - --- - __.__.__._.------- ------------- ------ This Permit Expires 1 Year From Date Issued Date Issued_.. a 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. 5499�aany existing Rules Regulat' -_._-_.CENSUS TRACT__ -.- -_-_ JOB ADDRESS/LOCA N---.1. __ , ` -V ' Owner's' Name -i�V = = Phone I u �. _ .----- -------------------City------- ---------------------- Address l k I --76- . tea_ :._____- - - - -- 43 3 S Contractor sName._ - � - 'e+� :License # � Phone._ -- ---------- � IL i3 1partment House E] Commercial ❑ Trailer Court E]Installation will.serve: Residence Motel ❑ Other-----------------------:_- --------- + Number„of living units:_----._1---.--Number of bedrooms__.3_.__Gdrbage Grinder__`._____Lot Size---..i��Qc'� I - ---------------- f N Water Supply: Public System and name------------ ---------------- ----- _Private i Character of soil to a depth of 3 feet: Sand ❑ Silt❑ ' Clay ❑ _ Peat❑ Sandy Loam 94--Clay Loam ❑ Hardpan ❑ d Adobe [r: Fill Material-- -- -----If yes, type-------------------------------- I (Plot plaEn, showing size of 1ot, location of system in relation to-w,ells,'_,b`uildings,.etc. must be placed on reverse side.) NEW INSTALLATION: (Nonseptic tank or seepage p1t perm. 1f 1:�yy_Iic s��e//wer is avail/able within 200 feet,) TREA7MENT [ ] '!SEPTIC TANK [�}— ` Size_- __�_._'/-. --__Liquid Depth. �s-------- PACKAGEl Capacity__C6-D�-----Type___'-"-__ --Material__ C -------- No: Compartments---- -----------./ -� j Distance to nearest: Well-...-------- �J- -------------------Foundation:_--___, 2 - Line_.____G_Q LEACHING LINE- �of Lines------- --------__---Length of each lima----�\ ��'�.--- .____:Total Length.'_____!_` _ r � 3 t/ � I pth Filter Material -- -r------ --------- -------------------------------- n --------- -------- ��1 `D' Box_Jy_ .__Type Filter Material !_-��De ound'ation---- Property Line_” _ � -- Distance to nearest-. Well CJ I I__/�___ ---- SST [. — Depth---1 = ' - Num er__.:-____-- '_-' �'' �� Filled Yes N Rock o Water Table Depth.__i_. '�------ -- \S'ize-- '--"?,-ff� ---------- Distance to ar neest:Well_..__ ___ ___________+_.____._ ---,Foundation__ -_-_-_-d:________.Prop, j - : 1 Line____ ---------- Permit __._ Prmit-Sanitation --:_- - =- -- - --------------REPAIR/ADDITION (Prev.. - :------------- ' �� Septic Tank (Specify -------------------- = � ---------=-- - -------:-----------�------------- ------ --------------- --------------- -- Disposal Field (Specify Requirements)--- ----- -- --- :-------------------------- V---------------------- ----------- - ---------------------------------- 1_1 ------------ --'------=--------------------- ------------------=------------- ---=-- ------------ ---------------,:— -_ ( f --------------- ------------ - ----- s I - - = ----- (Drew existing and required iaddition on re ease side) hereby certify that I have prepared this application and that-the work will -be:,,done=in-accordance with San Joaquin County Ordinances,' State Laws, and Rules and Regulations�of the San_Joaquin Local HealthDistr"ict. Homeowner or licensed agents signature certifies the following: F �P "I certify that in the performance of the work for which thWperMit-is**issued, I shall not employ any person.in such mdnner as to become subject t Workma Compensation laws. of California:'_: R Signed----------- --- = -_ O * �� --- Title-_ 4x411+ t k (If other than owner) ` u^ FOR DEPARTMENT USE ONLY - e APPLICATION ACCEPTED' BY--------.-=- --------DATE--------------------------------------------# DIVISIONOF LAND NUMBER ---- ---------------- --------=--------- ---- -----------------------------------------------------DATE------------ ------- -------------------- - ADDITIONALCOMMENTS.----=-----= ------------------------------- ----------------------------------------------------------------- -------------------------------------------------- ------------------------- - ------- --- ----- I I' ------------ -------- F--- ------ ------------------ _.------------ ------------------------------- ---------- . . - 1 ------------------ -- ---- -------------- = 7 = - ------ - y Final•Ir1S ection b 1—_'-. ---- �AN ------------------------- --- ----------- --------- -------- Date p Y= = = EH 13 2411 OAQUINLOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M ,1