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FOR OFFICE USE: rt�,r� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- -------------- --- ---------- Permit No._7r_�' �7(Complete in rip+cate) � - ---------------- ---------- ---- ---- I---- ----- ---- - 7 �,,�� Date Issued- ------------------- --------------------- -------------------------------- ssued_-....-._ _ __---------------------------------------------------._. This Permit Expires 1 Year Frm�Date-Issued Application is hereby made to the 5 6i 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: - .. 11 �� 11 I�// r •n�/f 3 � JOB ADDF!ESS/LOCATION. -_._! 7-'ir_�__.-. Q_. jt�/-QS EY`,Gf!_-1'-- -------------`----------.CENSUS TRACT---- ------- I Owner's Name-------- e- ULA.- --1.�'L-1 _`Als------------ ---------- ------' _ -----------------.Phone---- ----d�C--- ------- Address + /�� - -- - -- ------ - --- -------- t Cit Zip ►Z Contractor's Name--,-(�_�__-. /.LG.,..._ l i9- ; �� .------ License #__ 5�7•�l__-_Phone:... -- Installation,will serve: Residence �� 0 _ o � ier ❑r it Court ❑ A a�ttment House Commercial Trailer Motel Other + mber of living units:._/._ ______Number"of bed`roorras-,_. ___Garbage Grind.&r._ ___-_Lo Size___�/.Z'Q ----------------------------------- Nu Water Supply: Public System and name---- '---f------------------ t ___;Z= g = Private �- Character of soil to a depth of 3 feet: Sand,[] ;Silt L] Clay ❑ Peat ElSandy Loam flay Loam ❑ ] € Hardpan ❑' Adobe LI ; Fill Material-_-_.7.._.__If yes, type___________ t (Plot plan, showing size of lot, locat%n of sy tem in relation tow IIs buildings,`etc. must be placed on reverse side.) NEW INSTALLATION: (No septic td��,:i eepage pit permitted if'public sewer is available within 200 feet,] ,- PACKAGE TREATMENT [ ] : SEPTIC TANK [?�]� °Size___ _ `+ - ___. _____-____Liquid Depth________________----------- - -.. Cd aClt i . . d Capacity i Type!*' Material '_ No: Compartments ,----- ---- ------------- ---- J= u to nearest::We11_ ._ 1 __-- .,. Foundation._ Prop Line--------------------------- Distance } : €LEACHING LINE [ ]... No. of Lines'- -------------.Length of each line .___;_ __._.]_ Total.-Length F,___- rr i t - f i t i ;D' Box .---_`!--Type Iter Material- '______1_---Depth Filfer Material__a___--:____--i, --= Distance•. .._......�.-.._.f. -'. . . .� r..... � ...,. . . . . °-----, - -{--- {� to nearest: Well.,-_ cFoundationt-_ '_ -_ -Property Line-------- ----- __-_. "'; SEEPAGE PIT [ ] Depth_ jl? e"r. _._Dia a s-. _-.Number------------ - j Rock Filled :Yes EJ No E] r Water TablefiDepth,. -- Rk Size----------------------------------------------- 'D - -. _ ---._---- ' --...------ ---- .... ----- REPAIR/AlDDITIONSanitation nearest. Well= _____F�_�.._t.�..__ _.,Foundation__>_____________r______t_Prop. Line____._.______._._ Distance to (Prev.:[ ' ff= " Date_' `_ _=`...--------- -------- - - ] , Permit# " ---------- Date-- Septic Tank (Specify'Requirements)_ .kR_. .._._ .... . .... s Dis osal Field (Specify Req uirementsf '� t r °----------- ------ ---- ----------------------------- ---1 : _ -- -------- ------- - . =' f (Drawez'isting and required addition on reverse side) i I hereby certify that 1 have prepared this application and-that-the-work;will-be-don-e-iri accordance with San Joaquin County � Ordinances, State Laws, and Rules and Regulations of.the. San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: t "I certify aP in.the performance of'the work for which this permit is issued, -1 shall not employ any person in such manner as i to become subject to kman's. mpensation laws of California.". v Signed =- ------ --------- --------------------- -- ------'Owner i BY - - --- -- --_f. �. -- .------ -- -- - e 11 ` Titl ��7J�4 Y.. If other than 'owner 7 ,- ._.. ,:_ ,..._., ,_/�.: f "`FOR'DEPARTNIENT USE'ONLY t" - ( APPLICATION ACCEPTED BY - __:� :_ _..._ ' -- ------------.------------- --DATE - -: --------- DIVISION OF LAND NUMBER.----------=' -------- -- -------------- ------'-------------'-- -----------------------------------DATE ' -- ---`-- ADDITIONAL COMMENTS--.-' = I- -=---------- - ------------------------------ ---------------------- ---------------------- ----- ------------ -__.-R -_ _...__-____ _____ I ' -____-.-____ __ _______________________ ____._ice'__._.___.__ ---------------------------------------_________________._________.______. I �I. --: ---------------- ----- -------- -------------------- ----------- ---------------------------- ---------------------------------'----------------- - - ----------- - - --------- - ------------------------------------}- ---------------------------------'----- Final Ins ection b -- ___-�- _ -------- --- - Date- p y..� _. --------- ------------------------- - - EH 13 24 j SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21b77 REV. 7/76 3M