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FOR OFFICE USE: V APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ------------------------------ --------------------- (Complete in Triplicate) Permit No.��-_gip/�- t - This Permit Expires 1 Year From Date Issued Date Issued_//_! x:129' t ..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 Or[dinance No..549 and existing Rules and Regulations: 4 JOB ADDRESS/LOCATIC __.'_ :� . Owners Name.: .� - = -------------- ^._. . .a,4. .� TRACT.--.-.----.--.CENSUS- T r »..._... -. --- ----- ----. -- -- ------- ---------- / �� .f C i one---------- Address .: ----- ------- r . Y a7 r.: City_ - -` - -Zip- Contractor's Name -- -------;--- -- License:# B-Z—z t -- _Phone------- -------- --- Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court❑ Motel ❑ Other ; Number of living units:------13_____Number of bedrooms;,._ ___Garbage Grinder------------Lot Size_____________________}____ PPY� Public S ' Water Supply: stem and na e_Y�•��..•,•,�R� , � , System m ------------------- ------ i # RrA Character of soil to a depth••of 3 feet; sSand ❑ rSilt� 'Clay 0 Peat❑ Sandy Loam ❑ Tclay Loam ❑ { Private. Hardpan �'Ado,be ❑ .�. Fill„Material:_._-'_: -1f yes t Zype---:--- W -- ----- - ------ 6 {Plot plan, showing size of lot, location of systen')'j' rel tion to wells, buildsngs,�etc, must be plac�d`on reverse side.}f \} NEW INSTALLATION. [No "septic tank'or seepage pit permitted if public sewer is available within 200'feet,] PACKAGE TREATMENT [ ] SEPTIC TRNK""' �"'""�' " ;9 [ ] Size --- -------- -li uid_ Depth.'_ t r r iCa acit �,TYP� ''r. Material == - i '. P Y No. 'Comp rtments--------'------------ a [1 Nor afcLinesnearest:'`:Well. = - = Fouriaation = Prop. Line LEACHING LINT= r ____ ____ - Len th of each.line. p 1 + = y s g ----------- -- --------- --Total„Length, _. 'D'`Box_ —Type,Filter-Material:.--- _' ,Depth FiIter-Materia l ----------------- r� _. ;Distance to near est:'iWelf_._.___ _.FoundatFon __ -.___ ___ Property Line -_ SEEPAGE PIT ,i = - -- [ ] Depth_ - ---- -Diameter._ --------)Number_. = = I.Rock Filled Yes No �l . Water Table.Depth.__ Roc iz i ❑ k S' e - ------------------ 1 v a ] �. REPAIR/ADDITION Prev.•Sanitation Permit#_.'----..___.--J_ _ -Foundation-------------------___--- Prop. Line.---------' _=------__--- Distance'to nearest: Well------- ._.,___ te_ Septic Tank [Specify Requirements]-------- _- --- it T } I ! r == --- ---- ------ � . A. Disposal Field (Specify Requirements[.__._- ----- ___ } F {- -�- - -- , - li z - ---------------- ---- - l�. . , -- ---- - c '-h- ----- side) f. - ured.additonon reverse Draw existing andreq1 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`.. ; "I certify that in the perFormance'of the.work-for which this perniik-is issued I shall not employ an "' to become.subject, to Workman's.,Censation la/. -- "mp aliforniap p rson m suc m ne sSigned ------ ..-'-- - : -- --- Ownern ra BY - _. T'tle _ rs[If'other th-gn:owrier} ,iu 3 j FOR-DEPARTMENT USE ONLY; APPLICATION ACCEPTED BY_____ _--- -- ----------- -----------------DATE �- - Zs DIVISION OF LAND NUMBER-------------------- ------------- . :: .. ____..DATE_.DATE::-------------------------------- ADDITIONAL COMMENTS -- A -------------------- - ------------------ ----------------------------------------------- -----'------=- -------------- ------------ ------------------------------------------------- Final Inspection•b Date 7 - T - �Iz _ __ -------- EM f3 Z4 JOSAN A N LOCAL HEALTH DISTRICT F&s 21677 Rev, 776 see