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FOR OFFICE USE: FOR OFFICE USE: - .} APPLICATION FOR SANITATION PERMIT ----------------------------------- ------- ----- {--- Permit No._-7------------------ (Complete in Triplicate) ----------------------------- -------------------- ---- yo . Date Issued_.` 77 _ -____._.__ ------------------------------------------__..._.--__ __ This Permit Expires 'i 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---- ____ -1 -- - .` -_CENSUS TRACT . ---------------- ------ ------ Owner's --Owner's Name-� l�i�L .�.__l.� �'-� -'.�.e��,-'- --- -------------Ci_._--------,��- ��' - -------z _ �+ Phone Address----------P L 6 �"(�. ` tY h ip-G _� _ . Contractor's Name__ i_ Cj L v e J License # '�._Phone__ Installation williserve: Residence Apartment House.❑ -Commercial ❑ Trailer Court'❑ w_ w... Motel J❑. Other---------------------------------- - ----- Number of living units:__:___.__ _____Number of bedrooms ------,---_Garbage Grinder.__.;.--._-_Lot',Size_____�,�_..__.-__°.,.�..__. Water Supply: Pk blit System and�n.cime_____________ ;-u,)Z>,_------------------------ ------------------------------------------- -,-f--Private Character of soiLto a depth of-3 feet: Sand ❑ Silt ❑ '.Clay ❑ Peat ❑ Sandy Loam yr Clay Loam ❑ I .. Hardpan 0 Adobe 0 Fill Material------------If yes, type________________________._.___- i [Plot.plan, showing size of Ojelocation of system in relation to wells, buildings, etc. must be placed on reverse side.) ' NEW INSTALLATION: (No,septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENTI - [ ] SEPTIC TANK [ ] Size - �_--- Liquid Depth ;or Capacity ---------=Type---------- -Material--- --------- No 'Compartments -------------- ------------- 'Distance to nearest: Well------------------------ ------------------_Foundation-------------- ---- --Prop. Line- .-- _----------- -F11 LEACHING LINE [ ] No, of Lines - _,_-_.._____..`_. _,Length ok/each line----------�_--- ., - -Total Length---- ____,_ _ __ ( 'D' Box------------Type Filter Material_:___J- ---- _.Depth Filte?Mateol i .!_o,.___ ---------------- ;Distance.to nearest: Well------------------- Foundation-------------j ' __.1Propert, Line_ I SEEPAGE PIT [ ] De th_____________ Diameter____.___;___.___,___Number___: `� =----- ----- . p � _ , �ock Filled Yesi❑ No � # i? --------------------------- Water Table:De th.____ __ _____ £ .. "�: . ---- Foundat olne Prop. Line ----- - i REPAIR ADDITION Prev. Sanitation-Permit#_-- Date------------------- 1s ante o neares . e REPAIR/ADDITION --------------- ------ Septic:Tank (Specify Requirements) { ............................... - = -- `� -lJ- - --' - �i ,{ ed� � --------------- " -----------------Disposal Field Requirements). :/ : ------- -------------------- ----------- ------- ----- --- ---------------------- ---------------------------:---------- --------------- . .. (Draw existing and required dddifion:enTeverse side) } I hereby certify that I have prepared -this a.Ozpplication and That th�work� ill-�be^done in accordance with -San Joaquin County `Ordinances, Stcite Laws, and Rules and4Regu...-,1 sof 4the�5ah Joaquin-Local-Health District, Home owner or licensed agents signature certifies the following: ...'_* .1 0 . . ` "I certify that ire the performance of Hie Work-fo�--which-his perm t4rT ssued,-;I'shall not a ploy any person in such manner as to become subject Ap Workman's Compen-sation' laws f Ca)ifornla. Signed -- -- Ouvn-- er F . ' # I B ] 6 - ------ T ------------`---- =-------------- Y I -- ------ ---------- -------------- isle-----'--------------------------------------------------------- -- a � (if other fEian'owner) ...". _. ' : R .. , 1 F lt;DEPARTMP4T USE ONLY „ } ... -r- . ate,;.., APPLICATION_ACCE-PT.ED7BX.== ''= "� .� = ---------- ---- --- DA E - -----a ---------------------------- DIVISION OF LAND NUMBER=-------------------- ---- ------------------- _ -1 _— -------DATE----------- -- �.... ADDITIONAL—C-OMM'ENTS:----------------- -- - - ----- _ ' -_-------------------------- - -------------- :� _ x ------------------------- ----------- ------ ---------- --------------- ------- ---- ----- -------- ----------- ---- ------ I------------=---------- . • w ._.. � .Final�lns-inspection by:__ !iY ------_---------------- --------------- - Da#e._--- r SANEH 13 24 JOAQUI LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M