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" _� + FOR OFFICE USE: FOR'OFFICE USE; APPLICATION FOR SANITATION PERMIT ----------------------------- ------- Permit No. - "- --"""-"-"""- {Complete in Triplicate} ""---- ------------ --------------- --- Date Issued " - -----"-"--- l ------------------------ ------------------------ 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. ] This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION,-... -�lY=_---------- ` -- !A'y j_'1'YN�'Y D CENSUS TRACT Owner's Name ,- ' i _: �!/�J---------- ---------- _ } �� G. 4 ---'..------ - ----=- ----- -----i.Ci` _..--------t-------- -- ---Ph --Zip--:-:---------' ------- Address tY -- � 7`uGG "!Z" -- ------ ' _ ; „'� r��- __Phone 1 .. Contractor's Name_`. __-_ tiLicense #-r _/ Installation_will serve: Residence Apartment HouseCommercial ❑ Trailer Court ❑ , �, !�. a Motel=❑_TOfih`er—r ------------ N ----- Nub ____ Size i _.._mr Number of bedroomsGag&Grinder_. a f Water Supply: Public System and name------------------ --------------------------- A/- ------ ------------------------- Character , --- ----- - .P :,.- to _ riva Character o� soil to a depth of 3 feet: , Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam { ! I, Hardpan ❑ i Adobe❑ : Fill Material_ yes, type----------------- ! {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.1 NEW INSTALLATION: '{No`septic tank or seepage 'pit permitted if public sewer is available within 200 feet,} 1 y PACKAGE TREATMENT [ ] SEPTIC TANK [`J Size--- 'x- �,�- - 5 -----------------------Liquid Depth.U '-----------'---- r# Cial - --No. Com artmen acitY-/ ---- TypeP��G9Materts__- Distance'to nearest: Well--..4-0-:.-��________________Foundation...-��_"____-----_"-..Prop. Line-."., -_.".__.__ No. of Lines-. Length of each line.____ �_�-------- --_ ":___.Total Length ` Len . . 9 � :€--------------- LEACHING L1NE [ ] �-•?---;._ � -`- / e � - Material/ �De th Filter Material___'---_. __ AR 4 YP P /_; i ~Distance to nearest: Well D' Box---- 'to e Filter = - -.Foundation---�7 ----------Property Line �C.�- yy �" '-______ $ Rock Filled Yes No SEEPAGE PITti [ u �ept -----------'----{7iameter.-------------`z---.NNumber-- --------------- ❑ ❑ Water Table Depth" -----� -------- Sf Rack Size j Di'stance.to nearest: Weil _-_._.._ —\' clay f Prop. Line - REPAIR/ADDITION {Prey:Sanitation-Permit#=__:----=- ----------'. .�----- -" -- ------ - > = - _ - -1 Se tic Tank (Specify Re uir�xa�ents) - - , i�----- ---------------= P P Y q � +� 1. -- ^ ' -------------------------------------------------- Dislposal Fi ld (Specify Requirements),------- ''---- ---- - ---------- --/ ^=ii_ } = --------- ---------- --------------------------- --------------------- ------- --------- --- - fl fpp � ------------ ------ ' ------------------------------------------ -------------- i ' " (Draw existing and required addition:on •e"rse side) ` I hereby ce€ffify that I have prepared this application and•that the work will be cfbne in accordance.with San Joaquin County ` Ordinances! State Laws, and Rulesl_and Regulations of the/�San'raquin ocayHeal#fi Disf'rict 4Hgm-e owner or licensed agents signature certifies the following: "I certify that in the performance of'the work for which this hermit is issued, I shall not emploj any F rso in such manner as to become Isub 1,0b Workman's Compensation laws of Cciilifornia.". !� _ Ien _e. rSlgned. y w .._ ^_____-...__._____--_.-____ _______"_______-___-___.___-____.__. _ --------- ----------------------- _______ ."-._. .____By_ Titl (If'other than owner) I I FOR DEPARTMENT USE ONLY f' • ' ] APPLICATION ACCEPTED BY.:.__ .. - --- --------- ----------------------------DATE.------- > - DIVISION OF LAND NUMBER._ .� DATE i ._. ADDITIONALCOMMENTS------------------------------------- ,� `� 4=---------`.---r;� -.---------:-------------------------------------- -- ------------------------- ---------------------------=-- •-------------=--------------- ---V---_--------------`-A-A -�----------------------------'------------------------ ------- - ------------------'---------- --------- -------- ------------ ------ ----------- ------- --- -------"--='-- ----- - - - - ------- I Final�Ins ection,a - - -Date y :. : EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT y F&5 21677 REV. 7/76 3M