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FOR OFFICE'USE: FOR OFFICE USE: �„/ APPLICATION FOR SANITATION PERMIT ---------- ----------- ----------------- ------ 6 (Complete in Triplicate) Permit No.2_'-.$6_ ----------- j 4 - --I--�------ 1 -- -- -- ------------------ -..-- This Permit Expires 1 Ye'dr From Date Issued Date Issued.1P-/d.'� Application is hereby made to the San Joaquin Local Health District fora 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__ �- -- ----- � ------------ ---- ----- - ---- -r -------CEN SUS TRACT Owner's --- - � 1 Name.=--- [3_h.� � _ ,� . . _ - --- Phone._Address---- --------- ---- ` -------------- City--- rr {ZiP 5 Contractor's Name. F_ r ---=--------------License Phone,___J Installation will serve: Residence h ��Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel i . . off. � G------- --------- -------- -- ------ o: --Number, [ Number of livingunits:__.___�__� _ � � I' of bedrooms_ ter- arbage Grinder____.__..-:.Lot.Size-___._ �_.`�'`'`"' Water Supply: Public System and-name-,-- .--_.____.--- --`----_.1_- i -- -------=-------------- -- --Private Character of soil to a depth of 3 feet: Sand:❑ Silt❑ :Olay [I Peat ❑ Sandy Loam il] Clay Loam N— i Hardp"an ❑ Adobev❑, > Fill Materiai.___ + v If yes, type.--- -------- ------ ----- [Plot plan, showing size of lot, location of system4in relation to}wells, buildings, etc. must be�placed on reverse side.) f NEW INSTALLATION: [No se tic'tank or see a e ( '"'" P p g pit permitted if puE#!ic sewer is availa ie within 200 feet,) PA+CfKAGE TREATMENT SEPTIC'TANK '[ ---------------------, - :.._ . Liquid Depth '-------------------- -,± aNoCompartments------ .. ..Ca antY --------------- -Type. ----= Materil_.!t Distance:to nearest: Well---------- _._�Foundatlon-------- --- ------- --- rop. Line----------------LEACHING LINE oline - . . ._._ ---____- --------------------- Length f each- line.-------- --,: ----_---.Total Length ----------- -- i # D' Bok--;------ #,Type Filter Material---- Depth Filter Material- __________________ .. n -- - r Distance torn arest: Well-----� .__-Foundation------------ el __ ___ _ - __.Property Line----------------------- SEEPAGE PITi -[ l Depth---- -}t-;----Diarneterr-------------=----Number--- = � '--- = Rock 'Filled Ye ❑ N INe th---- rap -- ----------- ----------- . _.Rack Size--- ------------------------- -------------- -- 01'x' ater:Table D • .r- s Of Dstance tzs�neares� Wel!-� --- ------- - ------.Foundation-- ---------------------Prop. Line-------- ------ -----------v� ' tion Permit*__- _ " = Date - ) Septic Tank (Specify[Reg1uireme2 AIR ADDITION Prev_. Sanita ---� _ � Disposal Fjeld [Specify Requirementsl r - - .----- ----- - _ _, �S - - ------------- --- ------=--------- ., . -- -- ---- - ---- ---- ---- ------------------------' _ _---- 1. - .,_ _ _.__ ____ __. -_ s ___ __ [Draw existrng and required addlfion on reverse side) ,s - -- w=- I hereby certify that.I have-prepared this application-and that the work will-be done in accordance with San Joaquin Coun Ordinances, State laws; and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agenli signature certifies the following: r "1 certify,that en the perforrriance of the work for which this permit is issued, :1 shall not employ any person in such m nner as ' to become subje- ct cWorkman' . ompensa:t ion- laws of ..California ." Signed = O------- caner- Y - --------- - Title- -..-.` . 4 l i - s [If other..than'owner - FOR DEPARTMENT'LISE ONLY r. ' APPLICATION ACCEPTED BY $- ------- DATE. DIVISION OF LAND NUMBER.--..;-£- ----------------- -- ¢ - ------ ----------- ---------------------.----,------------.DATE_------------- --- ---------------- ------------ --COMMENTS----------,..---------------- - ----- - --------------------------------- ---�'" ------------------ - ------ Final Inspection by:-- - r -- ----------- ------------- -------- _------- -- - -------- -- ------ -Date---- EH a 13 24 SAN JOAQU LOCAL HEALTH DISTRICT r=as 21677 REV. 7176 3M