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� FOR OFFICE USE: APPLICATION FOR.-SANITATION PERMIT FOR OFFICE USE- -------------------------- - SE:---------------------------- -------------------- - (Complete in Triplicate) Permit No..-74f__ 3 --------------- (5 � Date Issued------"-----7------- I --------------------------------------------------------- This Permit Expires 1 Year From Date Issued�4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and installt k r in s r' ed. This application is made in compliance with County Ordinance No. 549 and existing Rules and RegulatiorT's:' JOB ADDRESS/LOCATION ---------------- " - -. CENSUS TRACT.. ---- ------- � ------- .- Owner's Name-;------ l l /'�. �3.�G-�sC3-11�_� -------- ----- - -------------- -Phone-------- :---..----------=------------ Address .> l •� � &A- Ci .� G4r�d� Zi -- - city- , ' p--- -------------------------- 100 Contractor's Name------0141�(�,�.1 ........r7e v2�.� -'-------------- - License a�. t - ---Phone---- -7-/766 Installation will serve: Residence A artment House 17 Commercial Trailer Court. Motel ❑ Other--- 11F� Number.of living units:-__-------.---_Number of bedrooms------------Garbage Grinder._.;----Loi Size-.- -----------------------k_ Water�Supply:.Public System cind'name7---------------7--------- ---------------------------------------- .__.__ - ------Private X Character of soil to a depth of 3 feet: Sand ❑ 'Silt ❑ Clay ❑ ' Peat ❑ dandy Loam ❑ Clay Loom Hardpan ❑ . Adobe❑ Fill Material____--___- -if yes;type___--_---,-----_'---------------- (Plot plan, showing size of lot, location of system in relation towells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: ' '(N6 septic tank or seepage pit'permitted if pu bli�ewer is available w thin 200 feet,} j� I PACKAGE TREATMENT' [ 'I- SEPTIC TANK [-1 Size----J--__i l ___'---- ----------- ---Liquid Depth ............... N' •. Ca acit /.2- __- No.•-Comatmenel ats--.-:- ---------------- -- --- Distance:to nearest: Line-----4Z ,.. g.h d - ---- =_ Total Length.------y+�---- - LEACHING LINE [.] Na, of Lines------ Len th of each line.___'_-_ _ ! 4 D Box---f- -Type Filter Material x. pth�Fi�terrlUla et r.iaLa� r' '`k 5 Distance to r�arest: Well-- � --_Foundat on ' Q ----------. ::.----.-- -------- i Property Linei SEEPAGE PIT [ ] Depth--lo�._._`.�ameter-- i x Numb`er. Rock Filled Yes ❑ No'❑ i Water Table,Depth- ``-- -[ Rock4Size--------------------------------------------------- ( w ¢�� Distance to nearest:`Well --- - .............Foundation---`----- - - .Prop, Line------------------------A-1 r ,.. .# = Date- y I REPAIR/ADDITION {Preva Sanitation Permit#- ^'-- ------i 1 Sep'f,cT'ank [Specify Requirements)- `_ R; _. n. __---- = - Disposal Field (Specify.Requirements)------ -- --°- -----I. ............ -------------- --------------------------------------- -=---------------------------------=-----------. _. --------- ----- ---- -- ----- ----- --------------- --------=--- - ----------------------------------- s --------------------------------- -------------- -.--------- ----- 1� (Draw existingnd required dddition:on reverse sideM - -,_,Fhereby certify thata have prepared.-this application and thatthe work will- be.done in accordance- with San Joaquin'County Ordinances, State Caws'. and Rules'and Regula ons of;the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify that in the performance-of the work for which this permit iso issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California.':'. ? � - 6 Signed --- -- ----------t -- -- Owner Byf®i' ?'f = Title---- (If itle.(If other than:owner) r —FOR PA&WENT USE ONLY APPLICATION ACCEPTED BY- - ------------ ------ -- - ----------------------- -------DATE.-fes f; -- ' DIVISION OF LAND NUMBER--- --- - ----------- ----------- --------- -'------ •- DATE - f o 1 i - --------- t ------ ----------`------ --------------------- -------------------------------------------- ADDITIONAL COMMENTS___--------=-- ------- ?_ . . f --------------- -- -------------------- ---------------------- ------ ---------------------------------- -------•----------------------------- ------ -----------'----------------------------------- ------ ---------------------------- --------------------------------- ---------- ------------------ ------------=-- --------------------------------------------- Final ---------------------:---------- ------ -- Final Inspection by:-_------�-- --- - -- -- - --------------------- ---------------------------------- = ----------- ------ L EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT F&s 21677 REV- 7 6 �,,