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FOR OFFICE USE: FOR OFFICE.USE: APPLICATION FOR SANITATION PERMIT a/ ---- ------------------------------------------- -- Permit No.- 7`----.------- (Complete in Triplicate) ---- ------------------------------- t /3:' 2,2 Date Issued_ZI.-._J._.- -------------- This Permit Expires 1 Yea From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit1to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and-existing Rules and Regulations. + f/�ti -----------------CENSUS TRAC ------------ JOB ADDRESS/LOCATIC 741v _-- __- j;— o E Owner's Name ----- ------ - --- - ------- _ - ------------ _ - -------- ; Address--- --- ----=------ - -- ------------------------ ----- ----Zip-- C Contractor's Name --------------= 7.Z/--.---Phone....� License #_ o__s Ins�tallation,will serve: Residence Motel House❑ Con-m"ercial ❑ =Trailer Court ❑ I [ ` �. ; ❑ her----=---------------------'.-__...----- Number of living units:- --- ------Number of bedrooms:--.3-=--Garbage.Gr n e,r--==::---.-_-Lot.Size--.--L.-,9 ..°.-___-_-__.-----._"---.------ Water Supply: Public System and�name : _ _ ---------------- #--- '-- Privete,* Character of soil to a depth of 3 feet:' Sand ❑ -Silt❑ ;.Clay ❑ Peat Sandy-Loam ❑ Clay Loam R�-� Hardpan ❑ ' Adobe❑ Fill Material___ ______If ns,-t ----- t.______ i 43 (Plot plan, showing size of lot, location of system in relation to wells, buildings,�etc. must be placed on reverse side.) NEW INSTALLATION:' (No septic tank or seepage -pit perrriitted'if public sewer is available withir 200 feet,) , PACKAGE TREATMENT [']' SEPTIC TANK [']- Size, ------ 5______:----' '- --- ----- -------"- _ Liquid Depth.-------------. Capacity--- --=--------------TYpeataria!__.rr.._i------.------ --No: Cotnpartmen#s-- ------------------- - M I Distance to.nearest: We --- ------Foundation. =__-_-_::-_:-Prop. Line.,-- LEACHING LINE [ ] No,.of , ,Lnes-____ ..__._ : _ __. __ - -'Length of each ,line.__.,_.__j._ ._.-„__.::__.=_.Total,Length.___.._-___._,__._______________(_---------- f :'D' Box------------Type Filter Material--------------------Depth Filter Material-_'_- ----_ ---------------- ----------------------------k :-- Distance to,nearest: Well y ---._ �__ _Foundation” _ . :. _ -_---Property Line----------------------- _. r i. ...__... p ,!1' hr-". ."_.""." : f... t.. -t - i� SEEPAGE 'PIT [ ] Depth_.__. _ fDiarneter_'__ _�__.:____.Number--------------------------------' ' r Rock Filled Yes❑ i No Table Dept-----------------= `~----- = Rock Size..----------------------------------------------- Water s ---------- -----:-- Disfdnce to nearest: Well_______________________"_____ ___.._.._____Fodation._. Prop, Line---- _-______ REPAIR/ADDITION (Prev. Sanitation Permit#._,_--- _--___._---" _____ _. Date_ - s } --- --:_ - ------- ! Septic Tank (Specify Requirements)--- - Q� - --- -- - p (Specify q tt F , /�yr� Disposal field (S ecif Re uirements)._--_..-! _- L� -�G"C c--- -- 7------•--. ----------------- I --------------- ----- ------------------------------------------------------------------------- --------------- ------------------------- ----------- - -- ------------------------------------------ -----; ---------- ---------� _ ! E; V�� -------- ---- --------------------------------------------------------------------------------------------- ------------ --- --------.--------- (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 JoaquintCounty Ordinances, State Laws, and Rules and Regulations of 1the 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 this permit is issued, I`shall not employ any person in such manner as to become subjec Work n's Compensation laws ofa California.." -. x -- Signed---------- -- ' ( Owner i ` By - 47itle t � If other than-owner FOR DEPARTMENT USE ONLY s TE APPLICATION ACCEPTED BY-'-- . .; E-- DA I -7 = DIVISION OF LAND NUMBER----._ _ _.._ j___ T_ ,_r.____ . DATENI ... ------------------- -F- ADDITIONAL - _ , '- - --r. = w . i ADDITIONAL COMMENTS----- --- ----- -- - - -------- - -- --- ----- --------------- --- �� -= ---•- - Final^Ins action b Date--'-- ------ - p Y:---_ - ---------_-_- ---- -- _7-_:_--- EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 7176 3M