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FOR OFFICE USE: . 4 FOR OFFICE USE: APPLICATION FOR,SANITATION PERMIT ---------------------------------------------------- (Complete in Triplicate) Permit No.__.7___ _7______ -----------------------------------------.--------------- Date lssued__&�/-_71" -------------------------------------------------_ _. -This Permit Expires 1 Year From Date Issued - kf'ti.r� Application is hereby made to the S r i,Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County OrWinae No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.: I � -1-----------------_-- _.CENSUS TRACT:. �/ ..........1� �[ Owner's Name. .----------:�-------------------- Phone- ---- E ! - _ S 0 - nn Address - f � ' _�-� ."----------------- tY ;Qd_e x-------------- Zip Contractor's Name------_________________!_.Aj-"Pa►_E 1s'-,(/-" __ r_ . ,_License # 71C _____Phone__09�= 142 57, � p D lns+aElationt#wil! serve: Residence Motel Apartment Commercial E] Trailer Court E]a 4 � _s ___-___Garbe a Grinder___._____- LSizeNumber of living units _____""Number of bedroomf ____ -� - 7--p------------------------- Water -----------------------Water Supply: Public System and name /{ ;----- =--- -------------------------------------------- Private .1 Character of soil to a depth of 3 feet: Sand ❑.,Z Silt-❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam r Hardpan ❑ Adobe ❑ Fill Material__.__.__-_--If yes,•type _____________________ i_ I (Plot plan, sh,6wing size of lot,'location of system in•relation to'wells, buildings, etc kilo-be pplaced on reverse side.) ti NEW INSTALLATION: - -(No septic tank or seepage pit permitted if public sewer ib-dV 1able~With n 200 feet,) - /_s�� PACKAGE TREATMENT [ ] SEPTIC TANK '" [, = ,,� Size+��___._ _ -f. ---_ -_-_____ `Liquid Depth___________ _______ -Capacity--I-Z_oo_ yp6 :---- "--.Material----------------="�� ;No:-Corripartments--------------------- -- .� Distance to nearest: Welly,..... t� --_ ,,_ __,.__;_Foundaii nn '_ - ___, ;:-.._Prop. Line-, ----------- LEACHING LINE ] No. of Lines._.__ ,._ Length 4ealme_ _ © -_ -_ h -_____ -_______________�_--- ------r D' Box__--_I____-Type Filter Material_ ___ __Depth Filter Material__.___!- ______________ ____--_- -- Distance to nearest: Well___9�-__-__ _ -_ __FoundationQ.=_r Property Lyne._________ --- SEEPAGE PIT._ [ ] Depth-----------------Diameter------------- ---Number___-:_--_---" __ _ _ _ - j Rock Filled Yes E] No ❑C F Water Table Depth---- --- = ----------------------- ----------------- -Rock'Size------------ - ---------'------------------- ,r r y Distance to nearest: Well.__-____.._____________ __ 4' . -.FUu—nd ',.n---. - ----------------Foundation----- -------- � Prop. Line-------------------------- . REPAIR.%AD'DITION (Prey: Sanitation Permit#---------------------------------------- -----Date----------------------- ---,k_ ) -- -- Septic:Tank (Specify Requirements)--------------------------- -------------------------=----------------------- -----------------------------------I------------------------ --------------r Disposal Field (Specify Requi.isements)---------------------- ----------------------------------- ------------------------------------------`---------------------------------------- r, f -----------------``------ .-- ---- 4 _.-_----------------------- "" (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 the performance of the work for which thisipermit'isfhMiued, I shall not employ any person in such manner as to beta ubject to 's�Compensation of`'California.'I— �� Signed- �i r \t 15? / .f "b�_�Ez' S' arow By--------------=-------------- I 1i ------------Title- __ __ �---------------- (if ----- ---- r --i (lf other than ow r)" �r�` FOR DEPARTMENTALISE ONLY APPLICATION ACCEPTED BY------ �'�t ,� / n = DATE.-1--1 i ---- ---------------------- DIVISION OF LAND NUMBER -- -------- ------------------------------------------------------DATE-------------- ADDITIONALCOMMENTS----------------------------------------------------------------------------------------------- --- ----------------- ----------------- ------------------- --- ------ ------------------- - ------ --- ----------------------------------------------------------------------------------------------------------------------------------------------- -- ----- - ------- ----- ---------------- ---- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --- I ------------------------------------------------ Final Inspection by----------------- Date - l'/. f EH 13 24 SAN JOA1djIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7176 3M