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.......... � f FOR OFFICE USE: Z FOR OFFICE USE: APPLICATION SOR SANITATION PERMIT � � z � Permit ----------------------------------- ---------- - - ------ {Complete in Triplicate} U-6" 77 ---- -------- Date Issued.-/ , ---- ____-.-_- 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- _ CENSUS TRACT------- --- ------------------ JOB ADDRESS/LOCATION-.°.-, -.-_ �-�1--.-- :� �� ne Name. /37�.' �P f Owners �.ei-�-- --- � -- �.- - --- --- -- - - - - -- ----- ------------------- „--. ._ �--- - -- C�ty-- .�S�l�� Zip--- -- . ---- Address-------- ...- -`"...c -► ��1 . IC..//-� --�.� ---- � Phone--- I Contractor's Name-----_ !`� _ --- -__ _- Q:�_.-��--:License #a�..-- - -'� , i 3 . .;,.. 1 lnstallation;will:serve: ; Residence,g Apartment House.❑ Commercial ❑ Trailer Court ❑ iF.. Motel ❑ Other =r ' ---- ----------- ----=- .�'_,r_Garbage Grinder__.._,_ Size- --.- _-- --��- ` Number of living units:.- ?__.__Number of bedroom s-,,- t I t U.PPIy: Public System.and name----:----------- ------=- -- ------- - .------------' ------------- - - ..Private Character of soil to a depth of 3 feet:y N Sand ❑ :silt ❑ f Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam --------- Water Hardpan ❑ ' Adobe,[] Fill Material---.-.--_--_If yes,type-- - ------------------------ (Plot plan, showing size of lot, location sysfem 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 available within 260 feet,) fi PACKAGE TREATMENT [...)..f-SEPTIC TANK—[ } Size------_----3.----k - ----X-=��-----------Liquid Depth------ �� -------:--- 1 .. 3 t - --- .Cap: i TyPeJ , Ml aeiai--aCompartments---------o undatiof__- -;Prop. Line----- 'Distance to nearest:Well-, —--------- -----------Fo (f f LEACHING LINE; [ 1 No. of Lines'A-. .-_-_:-----_Length of a h lines ��d------ ---,Total Lengt /------ � _„------------ 6 ,4 p - p ----- r D Box__: %Type.Filter Material.- --__/L e th Filter Materia--- -- -- X---_-:------ ------ r _... :.. .,. . . .. 4 �� Distance to nearest WeII .-/ f� .-A - Foundation___.- Property3Line.___- I a' Rock Filled Yes No De th_�� Diameter- r.e -----Number --= - ❑ ❑ :SEEPAGE PIT [ l �► P� l # - -• ems�'�"s,'r' ; -- " .. -- tiock lne,------- � } Water able De�th.-- �............................. --------� op�Lin�e ---__ Distance.to nearest. Well-'- --y --------- - ----Founda -!----�: ---�, REPAIR/ADDITION (Prev. Sanitation Permit#-- ------------•----- ------=-------------Date--------------------------------- -,-- ) �C Septic Tank (Specify Requirements) ----- •------ --------=-==------- -------------=-------------- - ----------- - - # / Disposal.Field (Specify Requirements)- ------: ---- ----- ------- -- -- -------------- --------------------------------------------------------- ---------------- ------------------------------------------------------------- -= y -I __ ---------- ------------------------------ w ---------- --- -------. _ _ , (Draw existing and required addition on reverse side) 40 ill b done in accordance'with San Joaquin County I hereby certify that I Le",'pr'epcired this application and that the work w e Ordinances, State Laws, and Rules.and Regulations of:the San Joaquin Local Health District, Home owner or licensed agents I signature certifies the following: ' i "I certify that in the performance of.the work for which this permit is issued, I shall not employ any person in such manner as to become sub'ect to Workman's Compensation laws .of California.:..'., ; i E Signed =- / --------------------: 4- �-G'1Q OwnBr i :le_- .. -. (If of er than•owner) FOR:D ARTMENT USE ONLY APPLICATION ACCEPTED. BY ---- ----------= ------------- -- DATE. o Y �. - --- -- DIVISION OF LAND NUMBER:-_: 7------ ------- ------------- -------------------------- DATE : - ' COMMENTS----------------------- _. -------- -------------- -------------------------------- ADDITIONAL -=----------- --------- --------- -------------- ------------------------------------------ - ----------- ------ --------- ---- ---------- - ------------- --- ------------------------ -------------------------------- Q Finallns ection b i!-'_._!_` - ' -------------- ------ ------------ -----•---- -Date"/-.-v--�=---`.7�--�--- = ------- i P y.� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fps 21677 REV. 776 rn