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,.., FOR61FFICE-USE: "Y/Y FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT --------------------- "N Permit No.-7 - ��-ZZ p P - --�--- - (Complete in Triplicate) ---- Date lssued.S ------ This Permit Expires 1 Year From Date Issued ---------------- Application is he ade to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appli a i e in compliance with County Ordinance No. 549 and existing Rules and Regulations: , - --•---- JOB ADDRESS/LO TION ____t _'�"� -- '�J --=----------------------------- ------.CENSUS TRACT---- �r Owner's Name_ ��ovTL i y .. Phone_. 7�a - /��^ C / �� ._ ' C1 --------- -- - Address_ ------ --- :--- ------- ---- -- ---- = cityP Contractor's Name. is :. ----- -------- -------- -------License #-_ fid _PhoneF_7i _= Installation will serve: Residence 0�Apartment House.❑ Commercial ❑ •Trailer Court ❑ + l Motel ❑ Other. ------ -------------- L - g K ge.(;r.lnder Lot Size..-. =------- = Number of living units:.- ' ._._ ______Number of bedrooms__ ._ _Garbo Water Supply: Public System and name__-_ -------------------- -- - - ---- -- ; -- -.Private �1 Character of soil to a depth of 3 feet: . Sand ilt❑ Clay ❑ Peat [❑ Sandy Loam ❑ Clay Loam ❑ f Hardpan ❑ Adobe ❑ Fill Material__- If yes, type--- ---------------- (Plot plan, showing size of lot, location of. system in relation to wells, buildings,-etc-must be=placed-one a se side ) > PACKAGE T1REATMENT [[No SEPTICTANK 'Size-.,,, a e c it Sizetted if -ublie sewer is available within 200 feet,)' septicp 9' p .p P f Liquid Depth -- ---------- - Cop _ . Material. ' -=-----------`No. Compartments- d � � kms. �� i ...Distance to nearest:.Well-, ------------.___ _=Foundation_�t__ __ _________Prop. Line.:��- _ GLEACHING LINE [ } �No. of Lines__•______._ -.._.__,.,_-.Length of each hne..__�FO ;,,,,„ ,,,,j Total Length _�f��__:____-_____________-- ' D' Box_ ; Type Filter Material: ___-Depth,Filter Moterial ---. & , a� Distance to nearest: Wel{ _. Foundation------------- __ _.Property Lire--,------- _ _ CD SEEPAGE PIT [ ] Depth----------- ` Diameter--;--------------- ----Number---: - i �-»-i Rock Fr�ifled��,[-] No ._ ater Table Depth- --- --------- - -------- _-Rock;Slze; ------------- W - .. 'Distance to nearest:Well.------------------------------------------Foundation -.------------•-----------Prop.rLine,}------------------- 1 REPAIR/ADDITION (Prev, Sanitation Permit#---------------------- ----:Date ------------------------------------ Septic --- ------- `--- -----------Se tic Tank.(S ecif Requirements)-.-- --------------------- --------------- ------- -- -- --=--------- -------------- ------ ---c�- Disposal Field (Specify Requirements)--.-.----'.----..-, ----------------------------------------- ---- -------------------=----------- ------------ ---------- --_---- -----`---------------------------------- ------------------- ----------------- ------------ ---------=--------_ ----------------- -- :.; -i r ;' [Draw existing and required addition on reverse side) ,_ t c C I hereby certify that I have prepared this application and -that the-work'will„be; done in accordance-with• 5�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: r r "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 subject to Workmqn's Compensation laws of California.” t Signed_: �i - -------- - -Ownecr -- . _---- . . • . By-: 1 T't I e t (If other Phan`owner) t.. i { FOR;DEPARTAkENT USE ONLY- ---------------------- NLY` r APPLICATION ACCEPTI=D' BY_ -------------------=--DATE.._ , ------------ DIVISION OF LAND NUMBER---------------- ---- = = ----- ---------.DATE.-------- --- ---- --`------.- -------------- �.. . . t ' ADDITIONAL COMMENTS---------------------------------------------------- ---------- :------:------ --- ------------------------------------ ------------ --------------------------------:-------- ------- ---------------------------- -------I----- ----------- ------ --------------------------------------------------------------------------------- ---- ____________________________________ _______ ___ ------- ____ ------ _____ __ _._ ,r -------------------------------------------------------- _�f _____ -__.._._._ Final Inspection by—.- _ r at -- -------- - ----------- p •--- ------ D e ::� F&5 21,577 REV. 7/76 3M 4 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT