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FOR. OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit -------- -------- ----------- ---- ------c2 ---- (Complete in Triplicate) Date Issued_.`- � ------- ---r 7 _-__ This Permit Expires I Year From Date Issued --------------- �' Application is hereby made to the San Joaqu+n Local'Healtha;',Distr"ict for a permit to construct and install the work herein described. This application is made in compliance wit#t County,Ordinance-N.o. 54'9 and existing Rules and Regulations: JOB ADDRESS/LOC ON---------- Vale* --- ---- / — } .-, -CENSUS S T ACT•• r --..Phone_7."p_�-�2Q Owner's Name_.___., _. _ . --- 1 Address_---- City .�`x - :; Zip--r-6�- 6 � � Contractor's Name - -Foie y 6-7 Phone_ -------- ---- A2 t. he` rf'S' �(I-------= License #��'�jt�$�� k w e Residence ❑ Apartment, House.❑ Commercial ❑ Trailer Court. ❑ i lns allation walk se�v t; Motel X Othera-"_R_ /e' -- � i : < --------- Nulmber,of.living..units:.._ -----------Number.of bedrooms --------Garbage Grinder--- -------- Size____.f�1 �-2 �---- --- Water Supply.,-Public System and name --,-_ : "� -"�. Private , Character of soil to a depth of 3 feet: , Sand ❑ :Silt-E] Clay ❑ ' Peat❑ Sandy Loam ❑ 'Clay Loam Hardpan ❑ Adob ''"__N Fill Material-.:..--------If Yes,type. _'---------------- (Plot plan, showing '•size bof lot, to t on:of'sy.stem in relation to'•wells, buildings etcmust be•placed on reverse side.) .� NEW INSTALLATION:' (No=se.ptic,ta�k or seepage .pit ermitted if ublic'.sewer is available within 200 feet,) PACKAGE'T�REATMENT ,[ ] SEPTIC TANK L`l Size------------ ------------- `= ----Liquid Depth:------ - S -- -� . .. 'k A No.;..Compartments--_----- "---------:-----_-:- -------------------------16---- 'Capacit '= = -- Te MatexiiaI o _ ; Foundation-1 a Prp. Line - .,Distance;to.nearest: Well_;----- _h of each line..-___.. -'--- - ----Total,Len th -------------------- ------=---------- LEACHNGLINE- No. of Lines---------- - - Lengti •I . . _ .. .. ._ .. i. Filter Mater, als'D' Box--!----------TYPa Filter Material_------ - -..D,e th ------------t,-,.----------------------------------------- , # Distances to nearest: Well -..._ _ --- Foundation.-._' -- Property Line.. __ - . ; Rock Fil!ed ,1e s❑ i o❑G SEEPAGE PIT Depth... .-----------Diameter ..Number. ---- izer - -------------------------- t Rock S ----- ateble+Depth ----. Foundtion Line - -----Distarce.to'nearest: We .. ar p r? :- ` j. REPAIR/ADDITION (Prev.-Sanitation Permit#-:c .:__-_ --------- -------- !,_;Date ----- • � '� : --- J m_14 � ._ Destlosal F e(Idp(S'eciRe Relr ulirements)... x �^-�i �+._.__.____: --------------=---- P P Y q !N.fJ.L# ' - --------- /,00� -- ----- - -----------------------------------------_ ----------------- ----------- ----- x -- j f (Draw existing and required addition-on reverse -side) `� I hereby certify That I have prepared'this application and that the work willu'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: !' ii "I certify that'i"i 'the performance ofithe work' for which this-peFmit is issued, 1 shall not employ any person in such manner as4 t to become subjec o Workman's Compensation..laws of California." j{�a I ' + . B Signeda- --- _ Title_- i - (If other than owner) FOR_D_EPARTMENT USE ONLY ' ------- f APPLICATION ACCEPTED BY--- �i `�' - ----- ---------- DATE;... `1�1. ' -t�--------------- - ' DIVISION OF LAND NUMBER'------ .__ ----- --------------- -------------- ----------------- DATE r ADDITIONALCOMMENTS ---- ------- - i -----------------------------------------------------------'---------------.------_----------- i ..__.�_ - Y_. .._:. ---------------•---------- - ----------- - ------•------ - - �- - - =--- - --- - ------------ ------------- --- ---------------------- . — , ----------------- Final -- ------.- ..Date � - �------ -inspectionection by: -- EH 13 24 1! SAN JOAQUIN LOCAL HEALTH DISTRICT a'E F&S'"21677 REV. 7/76 3M