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ii CGR-� �.•� FOR OFFICE USE: 1I '� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 ---------------------------- ll :Triplicate}_... . Permit No._____-- s ..� _. ._..A ( p .. .r . ----------------- ----------------------- --------------- r . om ete_i p L Date Issued__-_y=__7_? --------__________________.__..__;_.__._._.__.__.__ This Permit Ex' ires 1 Year From Date-issued Application is hereby made to the San JoaquinpLocal Health Distrjict fora permit to construct and install the work herein described. This application is made in compliance with County Ordin nce No. 579 ,d 54 �d existing Rules and Regulations: JOB ADDRESS/LOCATION. ___ ----------------------CENSUS TRA CT--_---:-------------------------- f -----------.----_-._._- : � .. �..Owner's Name--------- ------------Phone- ------ ------------ Address-------- -- --------- ------- -------------------- i City S/ dip Contractor's Name_�i1'71 _____._ �. _.�__ C-License #__-_ >3_Phone_,___ ��—p�eQ_7_ Installation will serve: Residence ❑ Apartment Housie l❑ Commercial L] Trailer Court E] Motel ❑ Other-- Number agelGrinde�r-- -------Lot Size Water Supply.. Public System and name______________ Ib' Number of living units:_ Number of bedrooms__._____.__.Gar ---------------------------Private ❑ g Pp Y� � - r�. Character of soil to a depth of 3 feet: Sand 0 Silt Clay a Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Matell_'__.__.__If yes, type.---;__,._,_,____._ (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc. must bie placed on reve}se side) NEW INSTALLATION: (No septic tank or seepage pit permitted if ublic sewer is available within 200 feetJ1 I ��r r� PACKAGE TREATMENT [ ] SEPTIC TANK Size�L_] D�_. f_-______t______________--------Liquid Depth-_5` __________.___ o Capacity p Type Lc�-_ jf Material t --No. Compartments,, ,,,.7,-------------------- -.Distance to nearest: Wel _ �� o � Ath of I -'----- = Foundation. ®-------- Prop:"tine -�=---------------------- LEACHING LINE Nd. of Lines-- - --------------------- g jea h line----/00-`--- --.Total Length -- - ---------------------------- De Depth Filter Material ----------<�..a___"�``---------------- D Sox.___,�-__:.Type Filter Material p Distance to nearest: We /01- M # Depth - -Diameter.,-----�---- -- Nuimber---------------------------------- =------•---.Property Line � -----�----------- - oundation_.. - Rock Filled Yes No SEEPAGE PIT I l p � -------- -�'----- Rock ❑ Water Table,De th.------- ------' `--- _ Size-------------------------------------E ---------- �I ] Distance to nearest: Well_____________________ ___ Foundation__.________._.._.,__ --Prop. Line._.____.____ - REPAIR/ADDITION (Prev. Sanitation Permit#: . ------------------- ------- �_ -- --�----------_z-,--D-ate--i----------- ------------------------------ 4 -- ------ Septic Tank (Specify Re uiremen _____________ -- ---------- -------- - --------------------------------- -- --�- °+� K1Fr �;�--r --,- -------- --- ------ -- Disposal Field (Specify Requirements)---------- --- ___ _ -------- ---------- _ ---------- ----------------------------- ; tea ------------------------------------------------ -------------- --------------------------- - ----��:------------------------- -- ----------------------------- T (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 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'tr e-performance of the.work for which this p{ermit is issued, I shall not employ any person in such manner as 9 -,6 -- ornia." . -- -- .;,. S' bedcome sub'e rT Workman's C ennssatii n aws o a 'i 1 By- ----------------------------------------------------t �� Tile (If other than' owner) €� OR DEPARTM9Nj USE ONLY APPLICATION ACCEPTED BY DATE --- ---- DIVISION OF LAND NUMBER. ---- i--=--------------- -------:------------------------DATE-_------------ ------------- ------- ADDITIONAL COMMENTS. 1L --------- ------------------------------ ------------------------- I --- - `-------------------------------- --------------- -------- ---- ----------- ---- -------- � ------------------------------------ -------------=------------ - ----- Final Inspection by �- I -----------------------------Date- �� . . Fps 21677 Rev. 7��6 snn EH 13 2A SAN JOAQUIN LOCAL HEALTH DISTRICT