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FOR OFFICE USE: FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT ------------------------------------------------------- 7 �S� (Complete in Triplicate) Permit No---- Date Issued__-61�:._L7_: _________________________________________________________ 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 thework herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ! JOB ADDRESS/LOCATION__r. I CENSUS _TRACT - ------- Owner's Name. + _CrU�----------- 11-6----- ---- - Plione---------------------------------------- Ad . Address -- --------- ----- - �- ---- -- - -- City ..._... - ---ZiP------------------------------ ----------------------------- ---------------------- -- Contractor"s Name = -----• ------- ` .--_License #,�2 S- 3y3 phone II r; :- .. 5 l�� Ap ❑ l Installation will:serve: Residence ,�, .• artment F�ouse Commercial ❑ ;Trailer Court r. -Motel ❑ ''Other[_ , -- ---- - ------ ---- -- g y :.-_-Garbage Grinder__._.__.,,_-Lot 9 Number-of,livin units:_ ?_ -_.___ Number.of"bedrooms. Size.___._._ Water Supply. Public System and name----- '1. -__-.- i_ ___ --___ x----------------------------------------------------------------' ------------------- -Private ❑ - th of 3 feet: Sand Silt Cla Peat yi :❑ ':'Clay Loam ❑ I t p ❑ ❑ Y ❑ ❑., . 5and Loa C aracfer o soi to a e Hardpanx Adobe.[] Fill Material .. _.__lf yes, type------------------- -1 .___. {Plat plan, showing size of lot, location of system in relation to wells, buildings, etc, must,, a placed on reverse side.) NEW INSTALLATION:- 'I[Ndsept i�'�tgri aftseepage pit permitted if public sewer is available within 206 feet,) _j TAN)Ct Size. -�---- -------- ------- - --Liquid Depth--- cr PACKAGE TREATMENT [ ] SEPTIC •. 1 \r x Capacity - Type: ---Material --------=- No. Compartments----------------------------------- LEACHING LIN>=. [ ] No. of Lines Well.'__ . =:Foundation Prop. Line _ Distance.to• � _ - - t 1 � ! 177 ' ____- ____:_._._ Length`of each line.___ Total Length ___ __/f-Q_______.___ ' ae 1 7 / pth Filter Material-------------------------------------------- ' •_ - �earest: Wel!_=��(�-�I-- Found , . ... / : -�-::---- { Type Filter Material � be D' Box Distance to ation--- -- =---------.Property Line_- -"�--__-- „ _ ----�-- SEEPAGE PIT`.,[ ] +.; Depih_ , _ F`Diamete Number___ --------------------- ______ _ _____ Rock Filled Yes f ] NoF[ - e...-epth---------------------------------------------t � =-----------Rock Size------------------------------------------------- Distance --------------------'------------- ------------ s �" Water Tabl 'Distance to nearest:Well ___ _Foundation " -- - Prop. Line. Y -(Prev r t ��" :Date ---- ------------- - - 1.- ----y . � s REPAIR/ADDITION- Prev:Sanitation ,Permit#11' - �- - Septic Tank (Specify,.Requirements)'--- "' -------------- -------- ,. ,. Disposal Field {Specify Requirements]-----------1a ------ --- --------------------------------------------------------- ---- -------------------------------------------- --------------------------------------------- '" ------ ---------------------1 _-.--------- ---------- - -------------------------------- ------ ---- �--- -- ----------------- - -------------------------------------------- -- - --------------------------- - R .' .�-[Draw existing and required addition;on'reverse side] � I 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 Health District..Home owner or licensed agents signature certifies the following:*. ' .moi, a "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.Workma .'s ompensbtion laws of California.". .. ` .Q Signed ------"" "µ Owner Y T ---------------- ---- �� [ P B f_ '; `'-"L rTitle :: - =--------------------------- o her =other;than owner s t `d' 4 JOR VEPARYMENT USE ONLY APPLICATION ACCEPTED' BY-- "� ---- - -- - - /�',O" ----------- ---- ----------- - ------=-----------DATE.- ----- = � ----------- ADDITIONAL COMMENTS'; ! DATE- ----- ------- --- -.-- ---.- ---.----- DIVISION OF LAND"NUMBER.___._.__-. _ ._ _.._ _ _ f�_____ ---. - ----------- ------ ----- - -------------------=------------------------- - ----- ' --- ------------ ------------------- ----------------•--------------------------------------j�-- ---- - -- - ------ ------ - -- -----A -- --- -- -- -- - ---------------------------------------------------------- / Inspection bY= = - = ='= " _ - -` ' - =�= - Date ., = EH 13 2a ;I N JOAQLIIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M r M y' n