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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------- ------ Ira - ----------- (Comp}efie in Triplicate) Permit o_______________ ----------------- --- Date Issued..ff?_'___�7 ..................... This Permit Expires 1 Ygar From Date Issued v� Application is hereby made to the San Joaquin-Local�plth,Distric. for a pe�it to constr and install the work herein described. This application is made in compliance with'County Ordinance No:--549 and existing Rules and Regulations: 7 JOB ADDRESS/LOCATION..//9p /Z ..- -- - : - va► �CENSUS TRACT- ------------------------------- Owner's Name--- ----Phone_ 8=__3.9s .. r» ----- -- ------ ---- ---------- -------------------------------- - - Address .,-' 6Siplx ------ ... ---------------------------------City-------------------------------- ---- ---- --Zip------ --------- -------- ---- Contractor's Name ....-.!!55e ?� ----- License #----------- ---- ----------Phone-------------------------- Installation will serve; Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ S 11.�-w -;.` r. - --Mo#el�=❑---- Other--•------•---------------------------------- Number of living units:-1-----------Number of bedrooms_ ___-Garbage.Grinder_ ---Lot Size...-. ./�_-/Y�r .---.-.._--._-------� Water Supply: Public System and name------------------------ =.----------------- ------------- ----------------------------------------------------- Private Character of`soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ ' Peat ❑ Sandy Loam Clay Loam ❑ { `Hardpan ❑ Adobe 0 Fill Material__ __-------If yes, type_______________-...___----...- (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 permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC-TANK[ ] 'Size-.�,i41S//y ...�y� " t� .___Liquid Depth--------------------------- Capacity------_, ?--- Type-------------------------Material--------------------------No. Compartments----------------------------------- PAXIN./L/INZQ Distance to nearest: Well.----------- ----- - ---------------------Foundation ------ ------------------Prop. Lin -------. LE [ ] No. of Lines.. ./___________________Length of each line.-.---;/ , .. -------- Length ____7-4?--- ----------------------- 'D' ----------..____ 'D' Box.Z------Type Filter Material AV2..,2.._...__Depth Filter Material-___ --------------------------------- r- t �.� G Distance to nearest: Well____ ..._..._Foundation___ G__ ____________Property Line_. ".._--__......__._.- ! t rEfP 6f,Pt1' [ ] h' U mete - /X ------Ni3mber--------/--------------------- RScik"� Nei;❑ ',Clr+i - Ierble-nth ------- ------ --------------------- 'Risk rz .2 - ----- 1. 1 Di.sta.u,ce,.to-ne6*es4-Well:,1=--IAIJ--- ----------------------'Foundcjfl1dn::.1Q.y----------.Prop,-L.ive.. _3_20A----- --- REPAIR/ADDITION (Prev. Sanitation Permit#--------- -.-- Date........................_._____.__--_________) ----------- -- - -�",----1- - z Septic Tank (Specify Requirements)-_--- _ . ., ,. _- .. ±�•�----27� --- - Dis osal Field (Specify Re uirements).�� K � n p P Y q 1 ,Y �� )e - -- -�.- -_D"- -t--------------------- ---- ---------------------------------------- ---------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 certify that in th erf r ce t eofior which this permit is issued, I shall not employ any person in such manner as to become subi t ma ompeion laws of California." Signed-X.- -- --- ---------------------Owner BY-------- ----------------- --- --------------------------------- - --------- -- ---------- - - ----------Title.------- ------ - - - (If other than owner) FORJDEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --- --------------------------------------------------DATE.--/-Z- -------------- .. DIVISION OF LAND NUMBER -------------------------- ------------------------DATE.--------------- - f --`/gg� _ !ADDITIONAL CO MENTS —$_ / -----. f i ---------- --------------------- -------------- ----------- ---------------------- - ------- -------------------------- ---------------- ---------- 44 Final Inspection by:.- Date -------------------------------------------- - - ----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M