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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit (Complete in Triplicate) -------------- -------------- - This Permit Expires 1 Year From Date Issued Date Issued--�:-�^_�-7 _ >i -- -------____ ----------------------- -- -- 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION.------- -�3 `------10�-� "`"� CENSUS TRACT.- --• ---- ---- --- ;.. - ✓- . 4 Y + -c2-"� Phone------------- �t_ -- --- ---- Owner's Name.-_-.x --------- Zip City.k- ---- Address--------- License one --- 1 - = - ----------;--- - Ph' :� Contractor's Name��_ - _�'--- --- , i Installation will sere: Residence [ Apartment House❑ Commercial ❑ Trailer Court+❑ - u. , ,-•Motel ❑ 'Other ------- --------------- -==--- �~ _] Number of-livind units------- - ------Number of.bedrooms._� Garbage Grinder ----- Lot Size- _-:_- a - ---- --- -- ' Water Supply: Public System and.'name----- - ----------------------------- ------------------ Peat ---- -- ----- = - Prl - - _ __ __ 'vate Character of soil to a depth of 3 feet: Sand ❑ Silt❑ .Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam.❑ , w . ..-s- .--.. - _ . . ! Harapan XJ Adobe ❑ Fill Material_-.---------If yes, type.__--.:-__;__-----..__--- (Plot plan, showing size of lot, location of.system in relation to wells, buildings, etc• must be placed on reverse side.} NEW INSTALLATION:' - -'(No'`septic fank nor seepage pit permitted ifpublic sewer is available within 200 feet,) Size- ------Liquid Depth.-----I c PACKAGE TREATMENT--[J` SEPTIC TANK [ ] " -------------- -�-°`='�°----------- -Capacity-=-:-=-:---- * -Type------------e---�-Material � =----- = � : No. Compartments f l Foundation----- --------------- --Prop. Line ...... = ------------ Distance _.. to nearesfi: Well__==-----------•------k--------=------ , iLength of each lire I .Total' Length..--------- -------- 1------- -=----- - LEACHING LINE, [ } No. of Lines------------------_---_--.- €€ 'D' Box--:---------Type Filter Material]--_--_`-------- ----Depth Filter Material------------------- - - - � - �^- # •fit- ---------- Distance to nearest: Well_______________E________--!Founclationl______-_--- ____-----_---.Property Li e------------, ._ - --- . ( ❑ N n i [ 1 Pt Diameter.- __=-Numbe R led Y :r SEEPAGE pit ------ - e� ❑ Y. _ . ..... . --- _ oc i o k Wap OTable Depth. `------=----- i - - - " ff -------- --� - - ..-l Rock Size' - . p e - -- t r. - +4 -. Dista e;to nearest: We11- W r = Foau6datio - = Prop. Line--------------------------- 11 i S---------- f? -- Date.r`- a f REPAIR/ADDITION(Erev-Sanitation-Per•mi#-#-:.- _..- t L € *fie ' ( -_ ' . ' Septic Tank jpeafy Requirements)---_-___ - - y i , .ry o.= f . -------- Disposal Fie ldt(Specify Requirements) i �' - - - -- mac ' -------- - Y _ 1_.�. �' -- - ---- - ---- --------j - = _ ------------- --- ----�---- ---------1---------------------- - --- �f-- - --�:h -- , i # ( raw existing and!requi,e�e additiontonl'reverse side), f ; have re ar'ed-this�.a lication .that he wo k w€ll :be (sone•in accordance with San Joaquin County f I hereby certify'thRt I pr p i pP Ordinances, State Laws;, and Rules end Regulations oFahe, Sart Joqutin LocalHealth District, Home owner or licensed agents signature certifies the following: ; I '� , I .- -r " certifythat in the erformance of"the work Tori i'+ th€ er ilit i's,'iss ed, 1 shall not employ any person in such manner as to become subject to W rkinan's Compensation Aaws of California.'tr: iI Owner --- _ s { ------------ ---------- -- other than[owner) - FOR. EPARTMENT USE ONLY ` € c { � DATE"' "..�..�,.-"".".. - APPL'ICA710N—ACCEPTED"BY Y =--- --- --- ---- ;- DIVISION OF LAND NUMBEf� : -- ------ ---------------------_ = ----.: DATE /% ~�.�� ------ _T --------------- -----COMMENTS------ ------- - _ _ € �..----------.,-_.. ------------------------------------------------- ------------------------- ------------------------------------------------ ------- ---------------------------------- ---------- ------- -------------- -------- -------------------------------- ---- - PF- - ,f_ ------------------------------------------------------- __----------------------- -- D Final Ins ection by: =' _ -" -- Datee?-/ p ---_`-- ---�`�- x+ + F8,5 21677 RFV. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r i a -j