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FOR OFFICE USE: FOR OFFICE USE: 4 APPLICATION FOR SANITATION PERMIT -- ---------- --------------------- 7 7_ 575 i (Complete in Triplicate) Permit o._.__-.__.___.__.____ ---__._ - This Permit Expires 1 Year From Date Issued Date Issued _! U'7� 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct arid install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: AV Z JOB ADDRESS/LOCATION--- �-_--•_--_• --_-_--�,�,...� �. . _. �= - �._.>_._ . F. . mENSUS,TRAC� -C-�-_L-t1_�,5� -Phone 3_3�"04 76 Adddness Name_ f ' <- -------- -- Ci zi Contractor's Name_- �-C .47 � � � � License #,1� Phone - - ...- � Motel `Other- - .... . �.. r Installation wr11 serve: Pesidence A"artment House.❑ cial [❑ Trailer Court ❑? -a'� p -- `- Commer - - t .. .j.,.. ,lt ❑ = - t Numberof.living units:- Number.of.bedrooms_''7-_._.Garbage Grinder---/-r---,_Lot Size--.- �f_�_�L.:..�, _ -_ci;aewd�(,� Water Su I Public-Sysferi�-anndname- - L, t ------------------------------- �r - `Private ❑ 1 :11 i. P P,.y Character of soil to a depth,of-3-feet: Sand Silt❑ Clay ❑ Peat❑ Sandy LoamOlay Loam ❑ i Hardpan_©_' Adobe ' - e-------------------------`'------- f- ❑ Fill'Material_. __y_ If typ yes, (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �r y # NEW,INSTALLATION:{ .(No septic tank or seepage pit permitted if public sewer is available vr;i:tl i 2.00 feet,) . ¢ PACKAGE TREATMENT [ SEPTIC TANK ['=J " Size----- �(,f0-__ __ I"__-'1-'_ "-- ----Liquid Depth-._,__. _— _ _ - --- 3 , 4 Capacity ��d____.__Type _ � Material__ No. Compartments __-_ Distpnce to nearest: Well- - !L._ - ___.___ Found /Sr fT___;:,Prop. Line_-�_��_'f-T ` -----=-- ation-- � QQ , LEACHING'LINE_ =�j ,No. of Lines ------ _________�____..Leng'th of each line - p.__- QFf tal ength.:_ 'D' Box :._._.Type Filter Material-)V-4< Depth FilterNl-6terr0144 _ __ --------------------------- y "Distanceto nearest:'.We11-- -!w=.-�_Foundation-� ----------Property Line .'___ ______________T__"'"'" ^°Q SEEPAGE--RF- [ Depth ld-- ''---.Diameter �:_-_-- - Z ----------------- Rock Filled Yes❑ No ❑h • - _Number__ #' Mp �. �t .W _ ----------------- lock Size Water Table Depth___:_____ ____ --R _ r i �"��-."� --- ----------------------- ------ ----- Foundation--:--- .Pro Line-------------- , 2 X 10 X D�sfar,ce to nearest: Weil'_______________ REPAIR/ADDITION (Prey Sanitation Permit#--------------------------- ---------------------Date_.__.._______.:___:___.-__ __ .- ------------- s SepticyTank (Specify Requirements)-------- ----- ----------i �'�--- = ::_-:-.--=-_--- -_:: Disposal Field (Specify Requirements)- ------------�'----'- ------'------ --- ' '------------ ------------- --- - tt _ - -'---'---------- -------- .- - ' ----------------------------'---------- ---------- ---------------------------------------' ------------------------- ----------.--------- ------ - - ------ • • i --------------- ------------------- (Draw existing and required addifion on reverse sides hereby certify that,I have prepared this application and that.th-e-work will- be done in accordance with San Joaquin County Ordinances, St�te Laws; and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifiL the following: i "I certify that in the performance of.the work fol which -thispermit is issued, I shall not employ_any person in such manner-as to become sub;ict to Workman's Compensation laws of California. Signed-------------- - _ ------------------------------------------------------------Owner BY- --------------------------------------------- --- ---- --- ---- ----Title------- `-: n ---- ---------------------------------------- (If ----------- ---------------------- r (If other than owner) ._ FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BYs..r - ------- ---- DATE._ �3��" 7 ,= = f DIVISION OF LAND NUMBER.---------------- ---------------- ---------------------------------- ---------------------DATE.----------------- -------:- ADDITIONAL OM ENTS -------- ------------------- --- ' ; � �. ___: _ ------ ------------------------ ' -- -------------------------- ---------- ---------------------------r-----------' x � - -------------,'--- ------------------ Final dnspection by: _ - -- �- Date - - EH 13 24 J 4 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 Rev. 7»6 3M