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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- l Permit No._ 7,9� 3 - (Complete in Triplicate) Date Issued----------------- This Permit Expires 1 Year From Date Issued i i Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. f This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations: JOS ADDRESS/LO ONS -f 5 = = CENSUS TRACT =_ Owner's Name._ ----- ffi - ---------- ----------- --------------------- 'All ------- Address-------- " , -:----�--- F l -------- ` 'City �_�. ZiP ; Contractor's License # � Phone: ` Installation will serve: Residen`cbg: Apartment House❑ Commercial ❑ Trailer Court ❑ - , !N Number of living units:"_"".�_r--""""Number of Motel ❑ Other___�•_____.--------------= _ __.."_ __"""__._ __. _ i bedrooms-,-----Garbage Grind Lot Size--/ -_ .___-- - NZ ----- ----------- Water Supply: Public System and name_' ,._ } -_--- ___ ,----------" Pnvpte Character of soil to a depth of 3 feet. San silt[: ] Clay ❑ : Peat ❑ Sandy Loam ❑ Cloy Loam ❑ $ Hardpan ❑ Aclo6d ❑ Fill Material-----?.- - _If yes, type----------------- ------ (Plot plan; showing size of lot, location of system in relation to,Wells, buildings, etc..must be placed on reverse side.) NEW INSTALLATION: "(No septicJtank or seepage }pit permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ ]" SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth.--:----------------------` Capacity -/Woo--- TYPe �eZE14^material---------- ------------ .-No. Compartments------ ------------� i ---Foundation".-- 0- " -----.Pro Line." -------- Distance to nearest: a/Vell-,-- 7-------- ---- - = P t ; t e LEACHING LINE [ ] -No-of-Llnes_-=----"i------ - .length �ch line.-- _ .34 Total Length -------- -------------------- F, D' Box T pe Filter Material- Depth Filter Material Distanewe o eare'..._#..-, - . . .-.,..• ,. � ..., :„;.;-------y_ -•----------- _/- ---# Y st: Well 5 ----- ------------Fou -------_ Property Line --)�- ----------------------- SEEPAGE PIT [ ] Depth.---f-_-.--_-.,-Di0'eter-�t--------------Number---.----------.-----_----_----_ _ Rack Filled Yes ❑ No P " --------- ---------•------ -----------Rock Size------- -.--- ----------------------------- Distance`to nearest: Well_._"' Water Table De t _______"_"."""_ = ------ ----------------- -----.Foundation-------------------------.Prop. Line-------- --------- REPAIR/ADDITION_(Prev:Sanitation'Per,mit#_ "_'-- --- - ------------------------------.Date-----------.__.-----------------_ ----------) Septic Tank (Specify Requirements)- = ------=.----- - - ---- Disposal Field,(Specify Requirements) -__.__s="?"_ ? '� ---- �^' -- -------�- _ -- --------- --------- ---------------- ---------------6y-- ----------------------- tjI ----- ---------------- ----- -.-. - - ---------- ---- tt t `""'.,�� a` -------- ----- - -------------- -- -------- ---------- --------------------------------- . _ _ .. i � � fib.`i.r L I � i ., (Draw ,xisting and required addition:on reverse side); 9 - hereby certify that 1 have prepared this-apptication-and-that the-work-will-be•-done-in�atcordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the- San Joaquin Local Health District. Home owner or licensed agents si nature certifies the following: I o "tteifiify that in the performance of;tliework For-which super tiissued, I shall riot employ any person in such manner as to become subject to Workman's Compensation lows of California." i Signed--- ----------------------- -------`------- --- - -------------- ------------ -� s iK --------------------------------------------- --- --------- ,.. . n�{ ! - [If &1*r than ower] R`r F FOR DEPAR MENT USE ONLY APPLICATION ACCEPTED BY_--- - -==----------------------------------------- --DATE------ DIVISIONOF LAND NUMBER--------------- -------------------------------- ----------------:---:.-------------- ---------------DATE------------------- ------------------------ ADDITIONAL-COMMENT — i '- --------- -- ==---------=--=-=---------- -- = = = =='==:�"_.._ =- -------------- ----------------- _ _ ---------------- -- --------------;----------------------- --------- i -----------------` ----------------=---------.------------------------ ----""". ----..--. o - --------------- --`----------------- -------- -- - - - -- -- - - - ---- --,/- -- - - Final .Ins action b ^"""'`" ` -------------- - Date--.-a-' � �_ - ---------- EM 13 24 SAN JOAQUIN LO AL HEALTH DISTRICT F&S 21677 REV. 7/76 3M }