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p�'� V FOR OFFICE USE: ` FOR OFFICE USE: til APPLICATION FOR SANITATION PERMIT --------------- - ------------- - ------------------------ Permit (Complete in Triplicate} -------------------- ---------- ------------------------- Date Issued_.fc-a-S--7 ------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local,Heafth Di5tr.ict for a permit to construct and.install the work herein described. { This application is made in complionce'vw0th County Ordinance Nb. 549 and existing Rules an,dlRegulations: a [ --- • _ �--�-' - _ _.ft�JL...-- .•----� ---:- .CENSUS`TRACT�y. E JOB ADDRESS/LOCATIO " l ---- ---- Y j F i Owner's Name..----- ------- - - -------- ------ --------------------- ------- ----------Phone------------------------------------- 4,0 - tY �. Zi Ci �- R '- �.: c. E Contractor's Name. � ,LL , --- -- icense #_ . Z- Z2 Phone_. --- -- --�� Apartment House.❑ .Commercial E] Trailer Court. E]installation will serve: Residence EJp t ...._.'r . 3.Motel ❑ Other--_` Number of.living units:___ ------Number of bedrooms:--_Z_Garbage Grinder--- -----.;-Lot,Size ' Private ------ --- --- is ter Chaara 5epof soputolla deSystem th of 3 eetme Sand Silt ElC Harlay; Peat ❑ Sandy Lmoam ❑ Clay E] 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.) NEW INSTALLATION: {Nonseptic tank or see ge pit pesrZetted ifs bliewe�rsis available within 200 feet,} pp } r;_6_'_1 -X_- Liquid Depth.._q-------------- ------ PACKAGE TREATMENT I ] SEPTIC TANK I ;6 Capacity;.IOZ42 G?,..' _- -- _TypeMaterial-- -�- --No, Compartments--:--- --- .�-:-------+--- lLine_` --- ---- -------Foun a i on•' -- e =°° = Prop. F I, LEACHING LINE I/�J/// No. ofcLinesneares�ell. -Length of each line,.-_,_--. Total; Length.___. _---------------:-------'- 'D' Box-_----h`Type Filter Material.... ------Depth Filter Material--=--- -- T ' Line 'Distance to nearest: Well_-__.. �_ Foundation_.- ---- -----Property _- -- i Rock l N f ----Number --__ SEEPAGE PIT L s1 Depth--)- Diame#er._ . " �- �--- = TM i ° ❑ .� ., i... 1! Filled R Yes. _____ - i ,•. , { Rock Size .. " 3---- -- ater Table Depth----------------- WQ� ff . 1 T . .: Foundation. Pro Line J Distance,to nearest: Well.':_.:_._ _ _-------- --- p- ""---- ----- -- --.Date ---------------------------------- Septic ----------- ------ ----- 1 REPAIR/ADDITION (Prev. Sanitation-Permit#___.____..__"_.________� - = - Se tic Tank (Specify Requirements)- --- -------------------------------------------------------------- -----------------------------------_ Disposal Field (Specify Requirements-)----------------- -------- ------------------------------------- ---- -------------- - = v '. ------------------------------------ = - ---- ----------------------------'---------------------------- --------------- ---------------- (Draw existing and required addition on reverse side] I hereby certify that`l have'prepared this application and that the worts will be done in accordance with San Joaquin County Ordinances, State Laws,sand Rules and Regulations of the San Joaquin Local Health District. Home owner or+licensed agents signature certifies the following:, \-,( 1 :�. "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to w6rkmcin'iy'°Cbrnpensatian law C lifornia.'," O� - � i 1 Owner enerSigned-- � ---- ------ --- - ---- ---------- By t --------=-------------------•-- (if other than,.ownerj- i i `FOR DEPARTMENT USE ONLY" �: DATE - APPLICATION ACCEPTED BY-.-- ------ C= DATE - 1- DIVISION OF LAND NUMBER---------- -------- -------------- ---- _. ADDITIONAL COMMENTS------------- ---------- -------- -----"---- -------- ---------------------------------------- 1 ----- - --- -- _ "' - - Final Inspection b - - n.r --� _ ----- ----- ate-�'--- - ---- - EH 13 24 SAN JOA IN LOCAL HEALTH DISTRICT F8S 21677 REV. 7/76 3M