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~ FOR OFFICE USE: FOR OFFICE USE: O/APPLICATION FOR SANITATION PERMIT B` � . ------------------------------------- ------------------- (Complete in Triplicate) Permit No -- ---- i - ----------------------- ------ Date Issued,//:r/ . This Permit Expires 1 Year From Date Issued f 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 OrdinanceNo. 5 9 and existing Rules and Regulations: F C JOB ADDRESS/LOCA ENSUS TRACT- C r/ - - f ne - ---- ------- -- -- Owner's Name_.__ = -. . x, :Pho �f i Address---- ------', !F- ---------f - ---------- ---------- ----- = City _. �. - �^ Zip - i --- -=------ License #�T7�"---_ Phohe--------------------------- Contractor's ------- ------�- -- Contractor's Name_��- ----------------- _ rte: -- �I p Commercial ❑ iTrailer Court Installation wi11 serve: »Residence Apar ouse.---"-"" }----------------- " i----Y�.. A Motel ❑ �f ------------ - =-- F Number of living u - ______Number�of bedrooms 7=" ____Garbage Grinder-___ __:=LothSiie_,_ :: '-- ------ nits:__ Water Supply: Public System and name-------------------------------------- -- ------------- - ---------------- ! - Private# P e93-1 Character of soil to a depth of 3 feet: Sand Q ISilt❑ Clay �at❑ ,rSandy Loam []! Clay Loam El f. 4 = s :Hardpan E] : Adobe-,I:! Fill Material .-,If yes, type--,; -------------- (Plot plan, showing size of lot, location of system In relation to welLs,,. ildings,'.e`tc. Jmustfbe placed on reverse side.) NEW INSTALLATION: ;(No'septic tank 'or seepage pit permitted if'public{sewer is ci a., able within 200 feet,[ w PACKAGE TREATMENT [ ] y SI=PTIC TANK {�}� _._ ll f--- [ Li uid Depth. ------------ Size - / q p i Capacity�� .._ :TYpe,'-A-4 :=F,`Material ---- --" ---N Compartments-------- = # _ ^ � Lines Foundationf --"-------------- ---: __.Prop.�Line------ ---------------- Distance r No. to`r-.earest: Well fer ach line, �. Totaen #h LEACHNG LINE[ of Lines---- ------- - ------ Length t ' BOxh-r� Type Filter Material-41f /Z--bepth/Filter Material _ ------------ D' �. ._ ._ : . . . . . ��...,,.�;�f�' / � � e� - . -- :-- fav Y----- ___"Foundation___ _ d st: Well �o ' "�-__ Property Line SEEPAGE PIT „�� Depth c 5 �a D y'• r ,f ,.. z ' Filled Ye N + yr iameter. k-- Numbe �`- V f R s C Water Table:Depth = � Rock Size-------------------------------------------- r fl ...f .._. . p� "Distanceto nearest: Well_ �_____ __.Foundation Prop. Line... REPAIR/ADDITION {Prev. Sanitation P,,ermit.# :-- -- -------:-- bate------_-----:-------------=------ -------------------------------- -------- ] ----- Septic Tank (Specify Requirements)- -ill e-- ---- ------ - == Ic- ' Disposal Field (specify Requirements) '---------- ---- = i -------------------- t ---� - --_------ ------ --------------=----- -- ----------- ------------ (Draw existing and required addition on reverse sided I hereby certify that:l 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: ' "I terrify that in the perFormonce of'-the work for which this permit is issued, I shall not employ any person in such manner as to become subject to. Workman' Compensation laws.of California." t - -- - ---- Signed---- -------'--------------- Ctwnsr F 1 -- ------ ---- ----- :.Title LJ.C�h --X - ------------------- BY ------- -- u - , {If otherthan owner) FOR DEPARTMENT USE ONLY ACCEI?TED I3Y ----- ---------- --- APPLICATIONDATE - r = --- ------- DIVISION OF LAND NUMBER --- -=-- ---- ----- - - --- -DATE - = $ ADDITIONAL COMMENTS--"-- ----- -------- --------------------------- -- ------------ - ---------- - --------------------------------------------- -- ---- ------------------------------- ------ -------------- - •----------- { ---------- -------------------------------- --Date. -- --�-- -1-�--- �=---=-- Final Inspection by EH 13 24 SAN JOAQ�OCAL HEALTH DISTRICT F&5 2177 REV. 7/76 3M