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': FOR OFFICE USE. `r APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: -� ------------------------- ---------- t. . lComplete in Triplicate) Permit No..7e-`_- =-- ------------------- ------ �.� 1 -- --------- - ------- This Permit Expires 'Year From Date Issued Date Issued-.8�1- _� --------------------- ---= -, Application is h&by 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: JOB-ADDRESS LOCATION s ~ y Q� _CENSUS TRACT. Owner's Name.;:--`e -..�.C?Jv- = v Phone --------------------- Address--------------vC 4.jy/,•�_- ' - 'T`P� , city (_? .... --- Contractor's Name'-'!'-- -.{- •,-.Tr� _7E ' I:icense Installation will sere: Residence ❑' Apartment House ❑ Commercial ❑ Trailer Court [� Number of living un i Motel❑ Other__ ,?Q_ 1: _ t � � ,E�t-1;_'7.1•, =11�_- umber of bedrooms.__ _-Garbage Grincler.__-____-_-__Lot,Size--j_r `./ i I ,✓ g I 7 -- - ------- Water Supply Public System and name---- --- - _ ' 1.° [ Cla ------------- -------- -- ------- -�--Private� t Character ofoil to d depth of 3 feet: Sand ❑ 'y ❑ Peat Sand Loam [ 'Clay Loam I v '-Silt % ❑ Y ❑ y t Hardpan ❑ - Adobe.L]7 Fill Material4_� _.}ilf;yes, type_ _______________ (Plot plan, sowing size of lot, location of.system in relation to'wells, buildings, etc.must be pl'ced on reverse side.[ NEW INSTAL'LATION:" [No septic tankor_ seepage :pit permitted'if�public sewer is available within 200 feet,] /9 > r ► PACKAGE TREATMENT '[ ] SEPTIC TAMC ['] Size_-6;-.V _1D� - /f • - � - ---- ---------- Liq�id Depth...�r�---------- Capacity.f F� 'TYPe1 G � i�Matarial---------- - -----------No. Com artrrients------ Foundation = Distance to nearest: Well.:.._,�_s_.. [ _ �rop. Line_ LEACHING LINE [ ] No. of Lines:- --------- ------Length of_each lme._,_ (� li' --.Total Length ~ -a D' Box_ _---:= Type Filter Material_/ i [ - a�. . X Depth Filter 7Material_ -_- ------------------ Distance - ----- R i 'earest; Wel!_h --�__.----_.Foundation___—e5--r`�--rope ty�Line._l�d--�____ � � SEEPAGE PIT [ ] De th___s__ Y - - 1. is ante o n Diameter-<------------ - Numb'er_--:---------------------- _-- Reck Filled Yes E] No s p• + Water Table De th -]-- ----]--------------t ---=------------------Rock Size---- -- - Distance,to nearest: We � t Foundation__:i = - - ..P'rop. Line- REPAIR/ADDITION (Preva Sanitation Permit#-- _---_-- i_--_--__----____\____ __ •_ ii i -- -----.Date------ftp`°-----�—�-=-�- --_-^ "`�%' Septic Tank (Specify!Requirements)-----'-------.--- = =----'- ------------= �" 1-- ------ _1 I y� --------- Disposal Field (Spec}ify Requirements)--.-.- -------------------------- equirements)__;,__-__.-_ _ I "' --- -----! ---------------------------- --- - ---- ------------ ------------------------------------- ----- -- = ` (! 1- -------- ---------- --------------- -- ------------ --------------------- g q _ .� L (Draw existm and re uired`adtlq'tionZf sid - ------------ � on e) e I hereby certify thatl have prepared this application and that the�worlIc ,II be one inn accordance wit San Joaquin County Ordinances, State Laws, and Rules and Regulations of the ' `� g5an Jo�rqulri�Lo�Egil Health'pstrict�`Home owner or licensed agents signature certifies th�e�following: i "I certify that in the performance'of the:'Work for which 'this ,ermit is issued, I shall not-employ-any-pgrson in such manner as I to become sub, to orkm n's Com ensaf,on laws o_fACplifornia.,. 'y A 1r r Signed "''"�` > - - ------- ------- - - BY` _ ---=--- - --------- Title------------_----- ------ .� • - - - -•-- Owner (If other thon .owner) . . ---------- FOR-DEPARTMENT -- -FOR-DEPARTMENT USE ONLY' } APPLICATION ACCEPTED BY.--.__rf //( �v� t > --- --:-=-------- --------------------------- --DATE. g� ----- -- 7 DIVISION OF LAND'NUMBER ..�. --------------------- -- ---------=----------- -------------•------ -------DATE. ADDITIONAL COMMENTS------------------------------- --------------------• --------------------- ----- ----- --------------- ---- --------------------- -------------------------------- --- : -- -------------------------------------------- --------- Final drispection by: ` �= _. �. ,-» . :--___Date: = /p -- -7 EH 13 sa SAN JOA U!N LOCAL HEALTH DISTRICT FSS 677 REV. 7/76 3M [/ }