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r� i FOR OFFICE USE: FOR OFFICE USE: 3 APPLICATION FOR SANITATION PERMIT Permit No..7.7_. .... 3 ..._....__................................ .............. .. ..... _. f (Complete in Triplicate) Date i, _ . .... ..... This Ps, 1 Expires 1 Year From Date Issued A^ lication is hareb made to the San Joaquin Local :Iealth District for a permit to construct and insthe work herein describ;di' ! PP y This application is made in compliance with County Cirriiriance No.549 and existing Rules and Regulations: 3 _ _. . i SCJ ......... ...�� CENSUS TRACT, z JOB ADDRESS/LOCATION. •-•�� ,'L�' r""' '+(2c ........... ..... Phone ............ Owner's Name.:.:� G ........................... .-.... Address'JI&I . . . .. .... ..... . ... . ......... . ........... .. 7 ,. - Contractor's Name............. License #. e......................... Phone ......................... .. . . f Installation will serve: es:dence�;+ A artmer:t Nouse❑ Commercial ❑ Trailer Court ❑ Motel ❑ 0 ........ ....................................PY w z :................r....._ .......... Number of living units:.......... ....Number of bedrooms_, .....,¢.,,Gorbage Grinder............Lot Size............... .................. ....................................................................Private ❑ Water Su of Public Systerr,and name. ... P Y t :. ❑ ❑ y Peat Sand Loom ❑ Clay Loam❑ : Charaster of soil to a depth of 3 feet: Sand Silt Cla ❑ ❑ Y , ..h Hardpan❑ Adobe . Fill Material............if yes,type..... ;.• .s (Plot plvn, showing size of lot, location of system in relation to wells,buildings,etc. muse be placed on reverse side i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' ::.._... ...Liquid Depth.._...:::.:._.:.._._ c� -. T Size._.---••••---------••-------• 1 s PACKAG_TREATMENT [ ) SEPTIC TANK [ ] . Capacity.::..:...............Type.......................Material.........................No. Compartments... .......Fou6dation.....__.._ �............Prop. Line....... ... ! Distance to nearest: Well...............•_•_• 1, : 7ofa1.Length .................................. 4 LEAC' HING LINE [ 1 No. of Lines.............................Length of each line...;.....:_. � 'D' Box............Type Filter Material...................Depth.Filter Aatena .. _--•---•. r .Foundation ...`..............Property Line............... x Distance to nearest:Well........................... .Diameter....................Number.._..... ^–................. Rock Filled Yes C] o❑ SEEPAGE PIT [ ) Depth............... 0. Water Table Depth.......................................... -.Rock Size:.._...._:._._;_ ...._.........._ .._... - Prop. L'me....................... ...................._Foundation---- Dist ance - to nearest:Well.................. ::.�::Date.....-:::_::•...._..__..'.... ) REPAIR/ADDITION (Nev.Sanitation Permit#.................. ( i Y Septic Tank(Specify.Requirements)...............................................7... +eacr 2�T �� ....._..�:.�slQ .... ---._ Disposal Field (Spec R rements)....`i/i SS i .................... ... td .................................................... .. :..... .... .. .... . (Draw existing and required addition on reverse side) . I hereby certify that I have prepared this appiicatn County ?on and that the work will Vocal Health DisMcbe done in t.Home owanc* withner or licensJoaquied agents i= Ordinances,' State Laws, and Rules and Regul-:tions of the San Joaquinx signature certifies the following: p arson in Much Minn-nor as > "1 certify that in the performance of the work for which th?s permit is issued, I shall not employ any p I i; to become sub act to Work an's Compensation laws of California." ; - y� 2 ......................Owner .......... ........................ ; '..J 1• Si n�rd,,w-• afiYL - i r 9 ' r :................. .............:_..:............ ._.._.._..............................Ti _---------itle._.. By... -- i' (If other than owner) FOR DEPAR ENT USE ONLY C ..............:...DATE...._.......... .. _..7........_ ... APPLICATION ACCEPTED BY....:._... DATE.---...:..................:.........__..._...... ......................... _............................................... : DIVISION OF LAND NUMBER.................._. x ................................................................ ADDITIONAL COMMENTS...................:.._......_........_. . ...... .. `.. ......__.:................................................................... ......................................................................................•....__.._....... ..,, �.4. .............. �• ............ ......................................•_• ._. S. ................................. ... .. ............. �.... .tea.. .. . - , ...... ................. �.... �Ga •� "'lr Date...................,+ G� Final Inspection by:....... ... •••-•- .. Fi3 21677 REV.7/76 7M •. '.• ei u u SAN JOAQUIN LOCAL HEALTH DISTRICT ;L - a•t