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FOR OFFICE USE: FOR OFFICE USE: 7. APPLICATION FOR SANITATION PERMIT �1,== Permit No.�. ..- ... / (Complete in Triplicate) Date IssuedA? 72; y ................................_--------....._., _�__.__ This Permit Expires 1 Year From Date Issued { Application is hereby made to the San Joaquihil-ci dl-Heaath District fora permit to construct and.install the work herein described. # This application is made in compliance with Count Ordinance No 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - -------------------------------- ------CENSUS TRACT.---------- .. Owner's Name ----- - - ------• --------------I----1--- ------------------ ----------Phone-'-- '-'--- --- Q'l : Address- ------ ---------- Y - Zip Contractor's Name S.+C 4 °� .` " A == "License # S �i� Phone".' �._h60� . � - Installation will serve: Residences Apartment House ❑ Commercial ❑ Trailer COUME] I _ G rba e Gr rider - k _► - Motel ❑ Other Number of-livin units:___ Number of bedrooms g g of Size.' ------'- ---- --- Water Supply: Public System and ria a-.---"- ---:---- # --- 'i -_- _;------ �'--- L ,L i^e, ---- Private}❑ y : f a Character of soil to a depth of 3 feet: , sand ❑ Silt ❑ Clay',❑ 1 Peat ❑ Sa y Loam ❑ _Clay Loam E Hardpan ❑ Adob --_ e Fill Material_____-_____-If yes, type............._. ' t s (Plot plan, showing size of A, location of sy�tem in relation to?wells, buildings;etc. must be placed on reverse side.) NEW INSTALLATION: (Noseptic tank -or seepage pint p itted if public sewer is available within 200 feet,) GE TREATMENT 9` , [ l SEPTIC TANK [ ]- Size--�""'�------ ---------�------------=------'---------- Liquid.,"1�eP --'--" - - PACKAGE � t � Ca acit s _Material.........5 _Gompartments p Y-- --=- '.--=----Type_. `- 1 ..---- ( Distance to nearest: Wel! .-_.- `._..,. _ * Fourida#ion---------------------------Prop.'Line --- . _ L _" " LEACHING LINE [ ] No,of Lines ;f {�'-----------------Length of each ,line- .._...-------.--..- Length....... . ---------------------------- 'D' .- .----- ----. - I D' Box- T iter Material-..- -- :.. Depth;Filter Material-----------------------'---------------------------------""-"-' 4 Distance to nearest: Well------------------- y ---Fou I -� -- ' ---Foundation_ �---- -------- Property Line = - ---- -- [ ] Depth :-.--Diameter: -=-------------Number---------------------------------� SEEPAGE PIT � - � - k p ''"�,."',.,";' Rock Filled Yes [] No'❑ A. ` Water_Table:_Depth ------------------------------------------------------Rock Size=-------------------- '------------------------. Dist&'nce'to nearest: Well--------;--------------------------=------.Foundation.-=------=------ ---- -.Prop. Line-- -------- ------- ------- '--:=::- '_-------------.Date--=----------`---- - ------------1 REPAIR/ADDITION (Prey:Sanitation Permit#-:°.:..._..-:.-.....-.. _ ..._.�___._ Septic Tank (Specify Requirements)- .- . ;i-o<' = Dislposal,Field [Sp cify Requirements) - -------------------------------------- - ------------------ _ --------------------------------------------------------------- --------------------- "....._" _" ." " (Draw existing and required addition on reverse side) I hereby certify that.] 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 Health District, Home owner or licensed agents signature certifies the following: "I certify that in+hnerformance 'of the.work for which this permit is issued, I shall not employ any person in such manner as �---- - I ------ ----- - -- -- ---- . k togbecom subjWorkman ss CCgmp'ensatioa• laws of California.'! f . � a Signed - - � - -- ------ -- --- - - "moi B - --------------------------------------- p = Title--'- 7- (If'other than"o'w"Re,r) � a ] `FOR DEPARTMENT USE'ONLY` r ` . _ -------------------------------------------------- a-APLICATION ACCEPTED BY = / -- -��------. --- DIVISION OF LAND NUMBS ------ - --------------------=------=---------------------------------•---DATE-------- ------- ---- - j ADDITIONAL COMMENTS-- ------- ---- ------------ ------- -----=------=-------------•----==------=--- --------+------------= ----- i ----------------- ------ ------------- -- ---------- - - --------=----------------------------------------------------------------------------------------------- ---- ------------- ------------------------ ------- -- ---- --- ---------------------------------- ---------------------------- :--------------`---- 7---_7-------:--- ------- --- Final Inspection by:-----"' l = ----- - -------- ------------------------------------------"------=----'---------- ---Date--- / --' ---- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M r