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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ ---------- --- ------------------ 7,7 (Complete in Triplicate) Permit No. _ This Permit Expires 1 Year Date Issued__ _�___ -_77 r� - p From Date,Issued O .. _ _ rA 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION. ---6-Q- ----l.,l/Y -.--pal---------------------L I_IglPe,07- ------CENSUS TRACT----- '----. 3 r0_(Z10._)/ � { r s Name --- -- '-�--W._�.---- -�-Q- - �-ri--- ------ -----------�--'---.--:� -- '-------- Phane - - ------- ----'-- Ovine .. r... .._. .• � - - - I Address `' = " Ci#Y t�`4Q�l -----' ---_-------ZiP------------------------------ Contractor's Name_.__�Jr__ _.r_L__.f y std l _+t{.. g.�'---A License #- -Z Phone..4Ls Installation will-serve) 12esidence Apartment House 11 Commercial E] Trailer Court E] "" - s �;• , Motel L] Other-------- ------------------ -------------------- i 1 Nu�mber.of living units: ,____._Number of bedroo Garbage.Grinder----------.--Lot.-Size___ � �-- --.._.---_._._.____._. Water Supply: Public System and,name---------------------------------=--- ----------------------=----- ---------------- ---------------------------Private Character of soil to a depth of 3 feet:—Sand I] Silt❑ 'Clay ❑ ' Peat ❑' Sandy Loam Q_Cla.y Loam Hardpan❑ ' Adobe Fill Material............If yes, type =--------- - -- t _ (Plot plan, showing size of lot, location of system in Yelation to wells, buildings, etc. must be placed on reverse side.) O NEW -INSTALLATION: (No"septic tank zor seepage pit permitted if public sewer is vailaUle within 2p0 fees} \ r PACKAGE TREATMENT [ ] ;SEPTIC TANK [:] ..., Size-----=-------------------`------`---------- ------- -----LiquidtD Pth = TYPe - ------ Material-----------------'#'-----'--No'Compartmen ---------------------------- capacity.t .. Distance-to nearest: Well_..... '-------------Foundation-- == Prop. Line = LEACHING LINE [ ] No. of.Lines------------------_„_..._,,,_:Length of each line___'---------------------.---._,Total Length -------------------------- 4 'D' Box_;---------Type Filter Material------- -_-----Depth Filter Material----- -------`-------------__----------------- ------------------Distance to nearest: Well....... -------------------Foundation------------------------------Property Line__-------_------------------------ SEEPAGE PIT [ 1 Depth_-.-.___._ - _ _ --.-Diameter_ __ --_. -_^_.---Number___ _____________ _______ J Rock Filled Yes ❑ No Water Table.Depth--- ___ '-_ '-- - Rock Size.----- �' -.- Distance.to n'ecire_st: Well.'...___'.----------------___________________Foundation Prop, Line--------------------------t REPAIR/ADDITION (Prev=Sanitation Permit#_______________ __ - ._ _ __ . t _ Septic Tank (Specify Requirements)-=- - - - .- ----:_ Dispose ield Specify Requirements)Z------- ---- -- --- --- - - f - �-, er ---------- ----- ---- --�' - ----- ��--- - - ----- ---- ----- y"{;f (Draw existing grid req"vire ddition,on reverse side] ^ I hereby certify that'l have-prepared this application and thaf the work will-be done" in accordance-wifh S`anJoaquin-County Ordinances, State.Laws, and Rules and iRegulations ofxthe_San Joaquin Local Health District, Home owner or licensed agents signature certifies the fallowing: / "I certify that in the performance o�-tie work,fo which this- permit is issued shall not employ any person in such manner as to beco wbjec to rkTan,s�om ensation laws of California.”. ._. . tEf Signe tr A--i:_ 5V--�- 1` r-.' � l} c n--- T.itie. � , � AA _,-''�(If other than ow r) d � �� t ��"✓, OR. PARTMENT US 'ONLY �' 1 J APPLICATION ACCEPTED-BY. : ----.DATA DIVISION OF LAND NUMBER -- 'w . - ------DATE.-_. -- -------- - ---------------------- ADDITIONAL-COA7INCENTS-' .. - i ----'------ -------- -------- - - ---------- --- --------- ------------- .. -- --------- ----------------------- --' --- - ------------_.------ n A ----- -------------------------- ---._ ___------------------ ------- .---------------------_-----------------------------_.------------ ------- ------ _________.. ---- ____ _ ___________________ ____ ----- _.`# _+._ .___ _ ------ - -------- ------.----_.----_---_---_-.------__ --------- ------- - 4 Final Inspection-by:_.. -"a- - - ---- ----- - - -------- ------- -- --Date -- -.. ------ -- ER EH 13 24 9" AN J AQUIN LOCAL HEALTH DISTRICT 1:&s 21677 REV. 7/76 3M