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FOR OFFICE USE: V� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -72_ �;7v �- Permit No----------------------- ,e (Co'nplete, in Triplicate) -------------------------------------------------------- Date Issued ------------------ r ---------------------- 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, p' This application is made:in compliance with County Ordinance No. 549 and existing Rules and Regulations: --- 2 i 4 JOB ADDRESS/LOCATION�.-.�..r� �..}�--- _. --------------------------------------------'------------CENSUS TRACT ----'-------- -------[--- , e _ ---.Phone_;__ Owner's Name---- -- :-- Address__ -- y ..... .. _ r City Phone 1 � 6( � Y ---- License;#_ � s Contractors Name;___.___ .___ Installation wilF serve:; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ G ; r ---------- Motel s_ Other Garber a Grinder_. ________Lot Size___ j F lg } � :g L �`� Number of.livin units------ __-.1__._-Number.of. bed a , . I f = rivet[ ❑ Water Supply: Public System and name----=------` : _ _.: - _::- _= >.-.. --- -_- Character of soil toga depth of 3 feet: Sand 0 `Silt ❑ Clay ❑ _ Peat ❑ SandFy Loam ❑ yClay Loam-E] i 1. i. HarcJpan-❑ 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 rev'erse side.) " 4 NEW INSTALLATION: (No [septic tank'or seepage''pit permitted if public sewer is available within 200 feet,J f A Size---_ ---------------------------Liquid Depth---� -- -" PACKAGE TREATMENT SEPTIC TANK " r Material:_ '----No. Compartments-- ---------------------- CapacitYl;; - ;TYPe i ,�z Dist�mce to nearest: Well-:_._-. =' ---.-'Foundation.,___1(, Prop. Line ---------------- LEACHING LINE [ No of Lies "_.._ ____ Length.of each lma.._ , ".Total Length _ �_ ._.--_. 4 ` 6 /� QepthFilterMaterial._ _ __.__ ------ ------- ---------- D,'�-Box-_._: __-Type Filter Material;__ _ _-_ i i Distance to n%crest: Well--------------- ------------ __ .- ----------=--- Foundation /e - Property Line__:"- - - . # SEEPAGE PIT [�Q Depth__�i �,__..Diameter__- -- --.,.___Number___-______?/_- _______ ' Rock Filled Yes: No Water Table Depth. Size 1� = , Rock b Distance to nearest: Well_..--__'_ __--------=------------- ------Foundation----/_----- -_._.`_.Prop. Line_:______-_ ----:- l REPAIR/ADDITION (Prev.,Sanitation Permit#------------------------=--•-----------'--------_.Date---------------------------------------------} Septic Tank (Specify Requirements)---------------------------- _--- -:-- ------,;------:----------_- --------------------------------=------_---------------------"-------k--- Disposal P (Specify equirementsl-------=------- - - -------------------- ------'------=------- -- ----------------osal Field (S [cif Ri -- -"------ - � _--------- - ----------- "" "--- - --- ' : ----- -- ---------------------- --------------------------------------------- -------------_---------,---------------------------------------------------------- -------_ - ---r--- I raw existin and required addition on reverse side D I hereby certify-that'll 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 LocalIHealth District. Home owner or licensed cigents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner ias to become subject to Workman's Compensation laws of California." }' , Signed__________________ }__-" -_ ___�_. . _._ __-__ 4_ ._._.__.;:__.___- --- ---- - Owner : i #. - G�i�'�. Title M --- ---=- ---------------- -----------------•- BY---------------= - �. [ [1f of er than owner} I i I_ -FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY---=---:---r ---=------------- -----------------DATE.----- --- -�.:-- ------ ------------- DIVISION OF LAND NUMBER:_ `- DATE------------------------ --------------- --- ,.. ---------- LY COMMENTS ------ --- ---- ------------------------------- --------------- --------- --'---- ---------- ------ ---- ---------- ---- ----------------------------- ------ --------------- -------------- ----- -------------- =---------------- ---- --------.--- -.-------------- -_.-------- ---- -- -- k a — ----- --- --- --------------------- ----------- ----- - -lt�7 -------------------------------------------------- D . ',. ' 1e -- ate: Final Inspection by.-.__�-_.._ _ - ' - - -- -- --- -- ------- ------.-- ----------- �- - .1 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ere 21R 7/76 3M