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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ -------- ------------ Permit {Complete in Triplicate) --------------------------------- Date Issued.,-_-1_-/dr--7 7 ---------- ---- - --------------------- 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. i This application is made in compliagcl,yy' aunty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION----_. -- -- /t�rtlt5� _� �tJ� ------ L ------..CENSUS TRACT.=----------- Owner's Name----- ice'- �rg &- _ -----------.. one �.: _ - nn i � '' �"-------Zip-- Address----" ?.ill2'l4r.."----- -- = = City, .- -------- /� [i -a Contractor s Name.0 �.:�,1_ _'.ZA L-�---------------------------License #- [357 (- `k_ Phone_. --------- i .. t.,. Ins'tallation,willTserve: Residence 0 Apartment House E] �C rrim rciQ al ❑] Trailer Court ❑ �� 4 Motel ❑ /./! - ,Other--- ---------=---" Number,of.living units:-----------------Number of.bedrooms.3_ . Garbage Grinder— LLot,Size--- ------------------'__.----- --__-....-._.--. Water Supply: Public System and name-------- ---------< ---_-_---------- -----=------------------ -- --- ------- ----------- --- - --------Private 8— Character of soil to a depth aneet: Adobe Silt Mat raa r Peat (] Sandy LoamClaq Loam ❑ p ❑ ❑ Y p ❑ . ❑ I _ !4f Yes.�YPet i c f t (Plot plan, showing size of lot, location of system in relation to wells, buildings';oic.!musi be placed on reverse side.) w E NEW INSTALLATION: ,[No se tic tank or seepage 4pit permitted if public sewer is available within 200 fleet,[ SEPTIC TAMC .[ ] Siie------ - - ----- -:_.-I--- ----------------- ----Liquid Depth l----- ;PACKAGE TREATMENT "[ ] r- -- -�- - -------="-- - E - --- -- P � L Distance to nearest: Well_.:... .,,._Fo��ation--- ----------- '`Prop. Line.=_------- 111 g --- --:-Z . . Length of each Line __-- -- _ ,---,Total Length-/� ,_- ------ .... LEACHING LINE [ ] No. of Lines _,:_.,_ ---------------" , , . 'D' Box--;- _Type Filter Material ------------- -----Det Fitter Material-- -_-- —_---___ -. -.-_ ._ i Distance to nearest. Well.`.__._ s------------ j, --Foundation--_: '-.-_"_-_ --:_.Propirty Line ..___.__ [ ] Depth Diameter-_ . ._Number__ ✓ ( (SEEPAGE PIT _ ll _ _ Rock Filled Yes o j------------------------- l t Water Table Depth �------=---------------------------------------- -Rock :Sizer-----------'� ----- j Distance to nearest: Well-----_--- - --------------- --.Foundation----------------- -------'.°:Prop. Line -------------------- _ Requirements):. . Date.-_" PAIR/ADDITION (Prev. Sanitation Permit#.__ ___ ___ :_. - --- _-" REi % --�--- VSeptic Tank {Specify,:Requirements) :......:......./ ------------ _ 1 ------1- -- i � ----- - -J ecifY Re uirements):_-_,-7 41"4 _ --- ----------- Disposal Field (S t s 1 ,t. � --------------------------------------------------i. ----------------------- ' : : : ::- --------------------------------= _-----------==--- --- : d ---------------------------�-- ---:--- ------------- l ' " ;Draw existing dnd re .u1Ted.addit1on orJ_rever_sesi el w- y .. --1 hereby certify that f,have prepared this application and that the -work_will.:be sdone` in-accofdance with San Joaquin County uOrdinarices, State Laws,+and Rules-and Regulations�'ofNthe San Joaquin Local Health District. Home owner or licensed agents i signature certifies the following- 4 A, I- 16 1 certify that in the performan`be--of-.the work forwhich thii'zpermit is issued, I shall`enot employ any person in such manner as to become subject to Workman's Compensationlaws"ofLColifornia " Signed - - _ -:Owner_ [- ----------- --- t BY- -- - - -- Title Gl1 -! - (if other than owner[ f , FOR-DEPARTM'ENT'USEfONCY 1 + DATE. ----------`------- APPLICATION ACCEPTED SY-------------�..__.. -- - - -- ---------- -- DIVISIONOF LAND NUMBER--------------=------------ - ------------------------------- ---.--..-----------------. ..--------------DATE-----------------------------------•----------- ADDITIONALCOMMENTS-------------- ----------=------------------------------------------------`----- ----------------- ------------------- -------------------------------------------- ----------------- -------- ---- --------------------------- ------------------ --------------------------------------- r t � - � - ---�- - ---------------------- ---------- ---- ----- ------ " .. Final Inspection by; . - -----.Date EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7176 3M