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'FOR OFFICE USE: FOR OFFICE USE: APPLICATibN F01t SANITATION PERMIT y ---------------- "(Complete--in-Triplicate)-- ""� I Permit No -------------------------------------------------- ., Date Issued. -----------_--- ----------------------------------- This Permit Expires 1 Year From Date Issued ..�' 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 Ordinance No. 549 and existing Rules and Regulations: I JOB ADDRESS/LOCATION Q,/ U -- --- ----------------------------------------------- - ----.CENSUS TRACT------- ---- -------- �. Owner's Name- � --1 ��-n- ( � -----:-Phone ;ry Address ` 0� GiG -- --------- ----- City_�l/ - P - - ----�---`--- ---------- ------ Zi ----- Contractor's Name ------------------------- -------------- --------------------- --- --------- ---------- -License #----- ----- Phone------------------------------ Contractor's will serve: Residence' Apartment House ❑ Commercial ❑ Trailer Court ❑ , Motel ❑ Other------------ ----------------------- -- Number of living units:--_---- .------Number of bedroo/�s�_.- -_Garbage Grinder- --.----Lot Size----A :-._ - Water Supply: Public System and name----------fL------ "`---------------------- -----------------------_7-----------------------------------------------------------Private ~Character of soitto a-depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe.❑ 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.) i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is vailable within 200 feet,] PACKAGE TREATMENT ] SEPTiC TANK [ ] ,/� Size--" --__1�1- ------- -------------------------------Liquid Depth :--- Ca acct l Bd dl T eX " C��i�_Material_ zflCV4__No: Co partments---_-_ a________ _ ______� p- y- -� --- YP p I CCS -4--------------:-Foundation ---�� a. . Prop. Line_-�a��rt,------f:' lstanlc� to nearest.Well.-..-"�-- ----- _ _ -- - -- -- �C�--------:-- C4 LEACHING LINE [ No. of'Lines--------"-+ ----"--_.,__.Length/�/jof each line - a_ rTotal Length _�-..- U---- 71-- 'D' Box------j----Type Filter Material__Wvc�-----Depth Filter Materia.lz�-'\\/_l _�,r� �-- --------- r t I 5 Foundation__- -__" o.-- PropertyLine-------- -- - t7--_- --_. 'TFa'stance to nearest: Well----�-1.--"I?7c7-- �-- - =- - - -U-- Z SEEPAGE PlT [ ] ,Depth_ -' Diameter_ , _L!1 __Number .-----------------_ ,/� Rock Filled Yes No❑ Water Table Depth--- Q-V ------------------- -.Rock Size----"---- "----- -� �... Distance_to_nearest: Well "- -", -----------------Foundation.--�!_.�J.►-1-` Prep. Line_"- __- ---.� (REPAIR/ADDITION (Prev. Sanitation ,Permit#-------------- ------------------------- -----Date-----------------"------------------------ ----) tl' Septic Tank (Specify Requirements)z`' i --------------------- ---------------------------=----------------------------- ------ ---------------------- ---------------------------------5 VDisposal Field (Specify Requirements)---------------------- ---- - tr ] --------- ----- ---- ------------- -------------------- -------------------- - ---- ---- --- - ---------------- --------=-------------------- ----------------------- ------------------------------------------- .......... ------------------------- -------------------- Vim`' (Draw existing and required addition on reverse side) I hereby certify that'I.-have-prepared this application and that the work will be done in. accordance with San Joaquin County Ordinance§„State La s,"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, it shall not employ any person in such manner as to become subiect to Work n's Com ensat, laws of California." Signed- �il-_T/l/11U. /lr Owner . _ BY- -------------------------=------- - --------------•-------------- ----=---------------------Title--------------------------------------------------------- ----------------- (if ------ -.----- (if other than owner) t - FOR DEPARTMENT USE ONLY` APPLICATION ACCEPTED BY --- --------------------- - --- ---- - -------- -------------------- :-------------- DATE. f� ---------------- - - DIVISION OF LAND NUMBER--- - -----------._DATE ---------------- - ----------------- ---------- ADDITIONALCOMMENTS"-------- --;------'-------------=-------- -------------------------------- ---------- --=---- --fi:-------------- ------------------------------------- ----------------------------------------- nd ---------------- -' = = - NT - - - ------------ - ------------------ --------------- A, ----------- f { Final Inspection-by:.:-C_1 Date_"r1�1.1-- -- r"1, k �'t`71 F�1677 REV. 7/76 3M EN 13 24 SANtJOAQUIN LO}CAL HEALTH DISTRICT