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-ellLiDatels FICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -.- l 1p7 t -------- (Complete in Triplicate) T i ----- 4 \ �' c� ` d. �«'- - ------------------ ------- ------------------- This ----- ------------------ ... , This Permit Expires 1 Year From Date Issued •-------- ------------------- -----------------------.-- 4 ruct and Application is hereby made to the San Joaquin .LocalOHealth DeSNo f44 ar dtexist ng Rultes and Reguiatior►s: ork herein described. This ap licatio is made in compliance._w.ith.County _ w 31 CENSUS TRACT. JOB ADDRESS/LOCA TION---- ---- . ........ Owner's Name------ -- ---- --- ---- ------------------------Phone.--------- � -- --- Zip. i Address.__..__ /t ----- --------City k:_ /- License #. I_�� --Phone--�� - Contractor's Name_ ReSLdence ❑ Apartment House ❑ Commercial , Trailer Court ❑ Installation will serve: , - Motel ❑_ Other--. w =W --- ---------- -------- ---- - s t .� — !J 4� Number of living units:---------- -----Number of be arb�e Grind_-..__-. ---Lot ize__..._--_--_ ----- private ❑ E ------- Supply: Public System and name--------------- ---- Water i Character of soil to,a depth of 3 feet: Sand ElSilt❑ Clay F-1Peat (] Sandy Loam El Clay Loam El k " kHardpan ❑ Adobe❑ Fill Material .._...-----If Yes, type-------------------------------- Piot ken, showing size hof lot, location of..system in relation to wells, buildings, etc, must be placed on reverse side.) I { p it permitted if public sewer is available within 200 feet,) _ ' NEW INSTALLATION: (No septic tank 'or�seepage p' p - Liquid Depth ._._ Size_ -- -- ----- ---- SEPTIC TANK [ ] � ? #" { PACKAGE TREATMENT { ] _ -No. Com artments__--- . i Capacity.-VO�---,Type ----P ------ Nla4__ - p - ;y ----------- / ly Distance to nearest: We11.. ----- Foundation--=-L --o--------------Prop. Line------ ------------------- e �. - Total Length .�r --------------------------- _/�No. of Lines-._:.�- - -----------------Lengt of each line._._ _. � - LEACHING LINE L a {" _ —. De thiFilter Material- ---- ----------------------------------- D' BoxType Filter Matenai_. -- -- p �. -Property Line--------- --------- ------------- Distance to nearest: Well------------------- -- ----------Foundation.---------------- --------------------- SEEPAGE PIT [ 1 ipep#h..--------- Diameter---------------------Number-- Rock Filled Yes ❑ N -Rock Size--- --------------------------------------- Water Table Depth._ ---- i Prop. Line Foundation--------- ---- - Distonce to nearest- We1i----------------------- I I ---�--Date -------------------------------------------- REPAIR/ADDITION {Priv Sanitation ermi =----- - --------------------- -------------- I;.. --= --------- - Septk Tank (Specify Requirements) --- - ------- - ---- -- --- ------------- --- ! ----------------------------------------- ------ ! Disposal Field (Specify Requirements)------------- ----------------------:-------- -------------------- -------I � - ---- - - -- - ------- - ----- - ----- ------- ------- -�--- - - - --------------------- --- --- ----------- } --- --------------- ---------------- --------------- (Draw existing and required addition on reverse side) i n accordance with San Joaquin County I hereby Certify that I have prepared this application and that the work will be done i Ordinances, State Laws, and Rules and Regulations of the San Joaquin;Local Health District, Home owner or licensed agents signature certifies the following: ? "I certify that in the peirformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." . ,�$� s Signed_ - Votht --- ------ ------ -- -------- --- Owner +�' F r -Title.---- -- t1f n owner) ' FOR�DEPARTMENT U E ONLY E kr �• Q__��--- ------ ------ �------ DATE.__- -- --- - --- ------ ------ ------ APPLICATION ACCEPTED BY--------------- - DATE. ------------- ------------- - ---------------- ------- - DIVISION OF LAND NUMBER--------------=------------------------- - ADDITIONAL COMMENTS_.._--------------- -- ---- ------ --- - ----------------•------------------ -------------------- -------------- --------- --W----- ---------- ` ------- D ---------------------- c Final Inspection b p y:=-- F85 21677 REV,7/75 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT