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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- i----------------------- --- - 'f '� (Complete in Triplicate) Permit No.._.7. _ - - - -------------------- -1------------------------------ -- Date Issued__.��.��:�� _________ _ __________II"_____.______.___._..._...___-._ This Permit Expires 1 Year From Date Issued I Application isEhereby 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 ADDRESSf LOCATION---- ': ---_ ._29 1-7 h-------�--------a�' --- CENSUS TRACT - C ---------------- Address e �caC��6hJ-..... ---�`-�`�,-'- �/-IRvf•�+��----Phone.----"---'- Owner's Name-=-- ---- --�--- �---- �--.---'-----'-- - -- ---------- Address---- -----------------------------------� -- ----- ---------- - City -------- ---Zip --- - -- --' 2��J �U License # 2 �_`i J� Phone_ �.Z Contractors Na •- •w ' ' -- 1 Installation will: serve: ` Residence ❑ Apartment House ❑ Commercial f)-,j ,Trailer Court ❑ / Motel Other:__57hb Qyi_-_4 Ai.)6A':-0_K J. ' FFU Number Ii 'I g uniT,r: Number of bedrooms___0_'____Garbage Grinde,r._. Lot,Size--------JT--------------------------------------------____ Water Supply P blic System and name:_- ------ ------------------------------------- ------- -------------------- ----- -Private, Character of soil to a depth of 3 feet: Sand� Silt❑ Clay ❑,w Peat ❑ Sandy Loam ❑ Clay Loam:❑ - w. _._ ^ • Hardpan❑ Adobe ❑ Fill Material_-___: -._-If yes, type-------------------------------- (Plot plan, s0u_ing size of lot, location of,system in relation to:wells, buildings, etc. must be placed on reverse side.) ]"NEW INSTAL�ATION:(r(No septic tank or seepage pit permiffed if pubfic sewer is available within 200 feet,] PACKAGE T EAMENSEPTIC TANK [ ] Size Depth._ ----- '3 tai Capacit�- ----- YPCompartments ,� • ----------- --T Type--- "-fes-'-�- -- - - Nj. -------- '- ----------------------- Distance '-- - " � Distance to nearest: Well-----------'-------- ..-_-.;--- --__Foundation.---- -'C-�--.----------Prop. Line--- .G.j-----'--:-------' 1Ut) Total Len �C3a nes---------- :. - .Length of each line--=: Length LEACHING LI " ._ }� ._ I ;�. - - E [ ] Do 13 x'_ .---Type Filter Material i 1L Dep#h Filter Material--------- �� ---------------- ---------------=----------- I: ..._. ,.. . Dstance1to nearest: Welj- -_/--(-Z--U--- -`------------Foundation -------- -c-------- _--.Property Line----""-2- --------------------------- SEEPAG -------__""-- _S� �] e -.-�--- �- '---.Number----'-.---::'-----------y------- : Rock Filled Yes E] No Wet r Table Deth- - Depth--."-' - ------ Diameter-p. --------------- '- -'-.Rock Size-------=---------- ---- --------------.------ ( Distance to nearest:'WeII-----------------------------------.-;------Foundation- ---------------- Prop. Line ----------------------- REPA10 XTfON �rev. Sanitation Permit#------ ---------------=-----'=-------- -=----.Date--------:--------------------- ------ ] \t! C§eptic Tank [i pecify Requirements) ----------- - ---------------------------- S -------------------------- i ----- ------'------------- ' ----------------- ,--------- -- ------`------------- _A ------------------------- ------------------- --d (Specify Requirements].;__:_._�,:_.__,:.,____,_ . Disposa Fie .t __________ _________ t _._________________.____-_____._.__._ _ ____`.__.___.___._-----._._____._____.__ F � ______________________________ ___________________________ __ ___ -------------------- _____ _ ` [Draw exisfing and equired addition-on reverse side} ' --- -" - J__ I hereby certify that I have prepared ;this.application and that.the work will be done in accordance with San Joaquin�County OrdinancesState Laws, and Rules and Regulations of the Sari Joaquin Local Health District. Home owner or licensed agents signature.-certifies the following: i ] "I certifyLL%iJhJalt in the performance of the work for which this permit is issued, I shall riot employ any person in such manner as y to become subject to Workman's Compensation' laws of California." . r Signed- - t-- - ---- ' -------------------------- --- -- -_- :Owner BY I�w+ --------- --- " -- --- -. ----------- ------------ ---------------- ------------_--- E�, ---------------- - Title [I'f other than'o ner] ` k 42 FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = . -"--' = DATE;l ----------------------- DIVISIONOF LAND NUMBER--------------=------ ------'----------------- ----------------- ------------- ---------------- --------------DATE.. ----- --- -------------------------- ---- ADDITIONALCOMMENTS---------- --------------------------------"--=-------------------- ------------=--=--------------------------------------------- ---- ---------------------_-----------. . - = ----------- ----------- -------------------------- ------- -------------------- f----------------------- ------------------------ Final,Inspection by:.----------- -------------- '-------_",`: --------------- ---' ---- -----------------------------Date --��----7 --= -------------------- i -=--- --------- EM 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r�°F85 21677 REV. 7/76 3M �� _ IO