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FOR OFFICE USE: F FOR OFFICE USE: f APPLICATION FOR SANITATION PERMIT ---------------------- --------------------------------- (Complete in Triplicate) Permit � ---------- ------------------------------------- - - f� �° i Date Issued-Y=14�J� ---------------------------------------- --- This Permit Expires 1 Year Frorri;Date Issued �l *,�:�� Application is hereby made to the San Joaquin Local ,}-lealth District f r'a permit to consfiruct and install the work herein described. • This application is made in compliance with-Counfy 6rd.i-n/ance No?S49 and existing R d Regulations: , JOB A,QQRESS/LO TION _c�j_,9- 4--_�4Q(`s O�--------------- -------- ---- TR } CENSUS ACT �� IPI'll I ' 1 `S = -----------Phone_. , Owner s Name-.-- /�-�-- Address. -e fy - .. --- - _ _ Zip ��-� ---------------- c?J- � /" U)2/fL14D --f - . City G f CC Contractor's Name -- - x(11 __-c.?�- LicensePhone_ t _ -•--- ' �- ------ le Installation will serve: Residence �Apartment House.❑ Commercial ❑-—Trailer-Court ❑ Motel ❑ Other_=Y ------------------------ ------------- a ... �/ Number of living units:________ -__ I t _ g f �� Number.of bedrooms Grinder._�._______LotuSize_._._..__..-'�--Glti1 - � - •------ --- �--- Water Supply: Public System and name _.__- :--------------------------------------------------- -- -_ -- - . ---- Prlvat � _ - e Char�ter�of soil to a depth of 3-feet: Sand ❑ Silt❑ Clay� Peat ❑ Sandy Loam ❑ Clay Loam ❑ _ E t Hardpan ❑' Adobe❑ " -Fill•Material_—:_• -_—If yes,-type:--"- —` --------------- (Plot tan, showing size of lot, location of:system in relation to wells, buildings, etc.;must be placed_ori;reverse;side.) r k, NEW"[INSTALLATION: (No septic tank ,or;seepage it permitted if pub!'ic`sewer is a`vpilable within 200 feet;) . Size - ` - - -; --- --- ----Liquid beth- ----------------- 'AGETREATMENT [ ] 4SEPTICTANK [ ] ;.__}_ � PACK T lE Capdcity Vii,." "' `hype___:.: ------------- -------:----------Material----------- No. Compartments , Foundation------- - -----------Prop. Line oo - Distance.to nearest: Well. __.=-- ..= -_-. N - _ Total Length W` LEACHING LINE [ ] No, of Lines.:------„ .:-.Length of each fins .__.-.__r .---=-_- :-.--- ► a 'D' Box. --- ; T p Filter Material`-_h----_ _ ------Depth Filter Material----------------------- ---- --- ------ Distance to nearest-..,Weil - ----------------- --- -_--=--Foundation. r .-� ---- --.Property Line -- --- - -------- ------ p _D a titer --------Number_-'--___-: Rock Filled Yes ❑ No ❑ SEEPAGE PIT [�] Depth-_ -._-- •, ��. .._. ---------------------- Rock Size + Water Table'D pth ____� - " Pro Line Distance to,nearest: Well t.-__. — - -. Foundation p. IR/ADDITION (Prev:Sanitation Permit#:_..____T__---:-- s- = -Date..... = = - - ] REP)Se ti y, - ------------ �--- ------------------- ----- c Tank (Specify Requirements) :----:.-- , /5�- Dis loss Field (Specify RequirementsL-------------- ------ , :. 16-ACL 6-- ;, al / -- z , -- -- --- --- ------ ------- ----------- '." -- --- --- a- -- -�- r {Draw existing and required addition on reverse side) I heY reh certify that I 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 certify that in the performance of the work for which this permit is issued, I shalt not erriploy any person in such manner as fy p l _ to Oe come su ' ct to kman's Compensation{: laws of California.'' Signed -.-- -- - --= r - - --- -------- - - OWne «; . ----- ----Title-- -=- - - - . (1'f otK6r than .owner) , . . { FOR DEPARTME T 5E ONLYr APPLICATION-ACCEPTED --------------------------- PATE DIVISION OF LAND NUMBER., - = -------- --- ----- - TE ----- ------- ----------------- - ADDITIONAL COMMENTS- -------'-------.- -- ------------------------------------------- ----- -- - - ----------- --- ---------------------------------------------- ---------------------------------- ----- -- -------------- --------- - t --------- --- -------- ------- = 00 i ----- Finc�l •ins ection b - - ------= --Da -- --- _ =-- --- -------- 4! F&5 21677 REV. 7/76 3m EH 13 24 SAN JOAQUIN LOCAL H ALTH DISTRICT