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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �7 --------------------- ................ . . w. J -;... Permit No...`...----..---�•'� (Com,-Iete 1n Triplicate] -----------------------------"...- n r Date •................"-.."-... ................. 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. ��..9D l �• /�A��i{1T *�� `�` '�_�Q�.l`�----------------CENSUS TRACT--.... "----.--.... Owne s; ame !.,R.1 V/- -------_-- ... ----- ---- --- -------- ---Phone--g4�7=41J.7� i .,Add'ress....- P©. X.. i .a .r'----------------City--... GAG.To!V... -Z'ip 9 a-P - Contractor's Name...,.. l...pae..tr. - Cts-Za� .........................License ----- Installation will serve: Residence IM Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other.........."-...... ------------=---•---------- ' �yia: a�� s Number of living units:-----�...-----Number of bedrooms"......Garbage Grinder............Lot Size., • # is Water Supply: Public System and name .:--•......... ............... ..��--"........----....------.---..............._..---. :.,......Private ,� a Character of soil to a depth of 3 feet: Sand ❑ Silt0 Clay'❑ Peat ❑ Sandy Loam[ Clay,Loam (3 Hardpan ❑ 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 revwse`side.) NEW INSTALLATION: (No"septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK HCl Size.--."197X9-X_-IC---------------------------------Liquid Depth......................------- � Capacity./P099-- .- LTYpe--P".CA.S.T.Material_4ZO�7?q7_No. Compartments.. �.-- --.--. - r _ Distance to nearest: Well_:.. /.. �f_ p__i----- ---------Foundation...../0. ...... .. -. Prop. Line-.,10e.�.......... — LEACHING LINENo. of Lines.......__ p(] .9...............:Length of each line...._.440..........-.-.--Total Length ...... D' ox_5'. ...Type Filter Material-/2- y..__.... ept cFilter Material......,. ......`..._. .........................::................. F t i D stance to nearest: Well.._.. Q.f"..........Foundation...149?t...............Property Line �......_.........-_. t SEEPAGE PIT �,1�f Depth.. d�..... -Diameter.. ��_��,,..'..Number.----.��...:......�._..'. Rock Filled Yes E' No❑ . ell Water Table Depth---------------------------------------------------------Rock Size__.�.. :a. Gc1RShFCA ,PDQ, tir Distance to nearest: Well---. eOW?. .................... Foundation_....f ?"...........Prop. Line..../..4f--......... REPAIR/ADDITION (Prev. Sanitation .....:..:....... .........................Dante....___-:-••-....-- ---------------------- Septic Tank (Specify Requirements) ,.r- _::__,: - = ------- -------------------------------------------- Disposal Field (Specify Requiremer'1ts)- ` w -------------- -----".........- = ...... M ---------------------------- •..---....--- -..-- '-----`----�---"---•--•--------•-i-�. :_-"- "'----------•----- .�......---..--`---------------.- -- ------'-'-' (brow existing and required addition on reverse side) I hereby certify that 1 have prepared-this application and that the work will-b—da a"in-accorclanc'e"with- San Joaquin"'County Ordinances, State Laws, and Rules` and,4 ulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the performance f(ie work for which this permit is issued, I shall not employ any person in such manner as E to become b)e /toorkman'sCompe ation laws of California." Signed.... --------Owner By..-- Title -------- (lf other than owner) , t r,._.. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY `* .... r-- A= ---------------• ................DATE -- �-a- ,1 { -=. • DIVISION OF LAND NUMBER.-_- _".__._...._.. . _;�. W ----------------------------------------- DATE---.'-.,.-LI ------------- ----------- ADDITIONAL COMMENTS......... ........... ...: ------------- --------------------- -.---............ -------------------- . ---- ------ --------- --"-------------------- •-------------------• ..--------..... ---------..-..-_------- --- .. ------ ------------------ ---------------- ---. -- -------------------------------------- ------------------------- ............---.---..... .. . . -------------------------------------------------------- - - ------........ ---------- ------------- ------------ --- ------------------ -- Inspection by: = --------------- ---------------Date.. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F65 21577 REV. 7/76 3M