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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit Na,.7-'__._�..__, ----------------------------------------- _________ __ This Permit Expires 1 Year From Date Issued +'Date Issue aS--27 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 Regations: JOB ADDRESS/LOCATION_._.+_.-- -� � /S O_G/$c- /Q!/[=-------------- ---------- ---__._...CENSUS TRACT---_------- Owner's Name. - -----r7�_-V - //3' �..._. . ---------- Ph AddressCdip r t Contractor's Name`__. i�, = `'� -- .'" License * Installation v✓ilE�serve t. Residence Apartment House ❑ Commercial ❑ :Trailer Court ❑ M oteOther •+....... +• a Number of living,units's _1--- ____Ni`�rrybw of.:bedro0ms.: __Garbage Grinder_._.__..._!-Lot-Size L..._ Water Supply: Public'�Sys�tem`and n-3Rie�' "-----'------_.��---_ �, -- _ ------ I------- -_ ---- -Private 4;.s Character of soil to a depth of 3 feet: - Sand [ Sil F�C y El [] Sandy[o'am X Clay Loam E) I _ `""`Hardpan-❑""`Adobe❑�"FillMaferial---- -------If Yes, type----- F------------------- ---- (Plot plan, sihowVing�ize of lot, location of.system in relation to wells, buildings, etc. must be placed on reverse side.) ; NEW INSTALLATION: [No septic tanker r-,seepage pit permitted if public sewer is available within 200 feet,) fes__.. r .i PACKAGE TREATMENT [ ]" , SEPTIC TANK- [ ] ,' Size----- ------------- -------------- ---------- -----------Liqui'd Depth.'-------;--------___--- ---=-- I f t Ca —Type-----------------------Mtrterial : . _ No. Compartments. .. -`--------------- l �_:Distbnce;to nearest:..Well =------------- ==------- - Fou ndation--------------------------Prop. Line ------- -=--- ------------ LEACHING LINE:, [ .] No, of Lines,__________________.'_____.Length of each line.,___._,__,.., .___- Total Length.'__.__:_.___.________ ______________!_ 'D' Box .Type Filter Material_ _ Depth Filter Material-------------------------------- ------------:. . .. . . „.: --- -, .Distance to nearest: Well -----------------F.oundation____ --------------------�*Pro er�y Line.____ - �.� , ..� _ •,�.�-ice � ., SEEPAGE PIT [ ] Depth. Diameter _ _____;_ wy t __.Rock Size._ 1 ❑�• _ R ____�__.___ _.__ ❑ . i Water Table:Depth Number Rock Filled Yes No --- ---- ---- -- - Distance to'nearest: Well- --- __.___:Foundation_ --- ------------------Pr p. Line ------ REPAIR/ADDITION _REPAIR/ADDITION (Prey._Sanitation Permit#----------- ----------------- --------Date---------:__,------~__---°-----1'----- ----- ---- Di� Deal Field Y q ) ---=---------------------------=----- -----------------` i ----.----------- --------------- Se otic Tank,S eaf Re �irements _ _______-- p d (Specify Requirements)-----.-/ lC '------Z?j4-`- ---- R_____________ ____________________________________ __________ ____ - - --- --------- - _. - ,- --- - ,-------- ------ ______ ____________'__.-__.___._________r____ _ ____-____ _____________-_--------____._______________ __ __--.-______..___.___._._____. _._ _____.._ _.___________E___ (Draw existing and required addition on reverse side) G I hereby.certify that I 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. Hoene owner or licensed agents signature certifies the following: : "I certify that in the performance of the work for which this permit is issued, .I shall'nof employ any person in such manner as tobecome-'subject Workman's Compensation laws of California." _. Sig ned -� sal Owner By!f By!------------ ----------- ----------------------- -------------- --------------------------- ------Title---------------------------- --- ---------------------------------------- � f (If 'ofher than-owner) ` r I' FOR DEP-..-.__-ARTM NT-USE ONCY. y' . 1�.. APPLICATION ACCEPTED, BY-` DIVISION OF-LAND NUMBER - ---- "" '"" — DATE -�-�--------- ------ --- - -------------------------- ADDITIONAL COMMENTS______________ --- - -------------------------------------------- - - ----------- --------- ---- ------ ------------------------------ ___________________ .._.---------------------- f.___-_______.______________._______.___. Final Inspection=bY•------=". ' _= -Date- "`i �/j --=----- ------- ---------- _'A6- A EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT as 21677 REV. 7176 3M [