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-FOR OFFICE USE: FOR OFFICE USE: APPLICATION FGV SANITATION PERMIT -------------------------------------------- Permit [Complete In Triplicate] Date ------------------------------------ .... .. This Permit Expires 1 Year From Date Issued 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'e'xisting'Rules and Regulations:" JOB ADDRESS/LOCATION---I.3/ Q °r'. 44J" - C ------- -------`--- - .-.---- .CENSUS TRACT-------------=------ ---------- do Owner's Name-'- �� '� - - ' - ' Phone " - . Address �lAi i :!C " City ��i" '"1° ��~ - '--Zip 6 _ ,._ -.,. :._ License #.. Contractor's Name.._... _ -- - - _Phone---------------- . p � ------------- ----- �y Motel Other.---:::Ont House ❑ aal ❑ jraiier Courtf❑ Instal lation'w111 serve: : Residence Apartment Number of living units: Number of.bedrooms:.. .._Garbage.Grindex Lot.Size -- ---------------- Water --- -.-- -Water Supply: Public System and name• - 1 ---------------`---�- -- ---- -------------------4--.-- -------- ------- ----------------i--- Private'❑ s Character of sol[ to a depth of 3 feet: . Sand ❑ :Silt❑ 'Clay❑ Peat ❑ Sandy Loam [ Clay Loam ❑ j Hardpan ❑ Adobe ❑ Fill Material.E.--__-___If yes, type-------------------------------- (Plot plan, showing size of lot, location of system in relation to:wells, buildings,letc. must be'placed on reverse side.) NEW INSTALLATION:' {No septic tank or seepage pit permitted if public,sewe r*is available within 200 feet,) , KA . SEPTIC TANK PACGE TREATMENT [.] [,`�],_ _� --size .: . w ._. �.._ ,, - - --"--"------ -- -- - -- � -_-____� _Liquid Depth _ a + -f. i .Capacity_._::"--, ;------:Type-- ------------------- ------- -- .. -.Material ;'No3 Compartments. } tl Distance to nearest:.Well. Foundation-.?= = Prop. Line G 3 LEACHING LINE:. ( ] Na. 'o# Lilies-:----"--------=-------------Len_gth_of each Eines... __----.- --- - -_=_._ _Length s_,_._.------I.---_. -_ --- " .'D' Box-----.----.-Type Filter Material------- ------..Depth Filter Material---------------------- ------ --- __ --________-___-- -Distance;to nearest: Well-----------------------------Foundation-_..----:-••----------------Property Line------------------------------- SEEPAGE PIT [ ] Depth-----------------Diameter........._...-- --:_Number__'-------------.-._..- ...+ Rock Filled Yes E] No ❑ Water Table'Depth-----------------'.-- ------------------------ ----------Rock Size-`---------------------------------------------•- Distance to'neare_st: Well-`•-----'------ -------- ----------- Foundation `------: ---------------Prop. Line - F ' fREPAIR/ADDITION (Prev:Sanitation Permit#_ � ___ _`_ _:-__'____________________'bate__ _"-l _ _.�f..__...-_.__Septic Tank (Specify Requirements)----------- ---- ) " _ -- = P Disposal Field (Specify Rrement�) .. ` .- ... ......... ........ .. ....... .. ., a (Draw existing`anc1 required addition on reverse sidej ; F l hereby certify that-1 have Prepared .this application,and ihat.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 the perforniance"of'the Work'for`.which this permit is issued, •1"shall not employ any person in such manner as to become. subject to Workman's Compensation' laws of California." ; R , Signed-------- ---------- -.....�.. -CYwnor �.Bt - l yA (If other than owner) FOR DEPARTMENT.USE ONLY t APPLICATION ACCEPTED BY: == = ` " 7 ------------ •_ DATE - Zai DIVISION OF LAND NUMBER--------------------- ------ - ADDITIONALCOMMENTS... ----------------------------------------------------- ----- -------------------------------- ------------------------------------------- " , ------------------------------------ -- ---------------- ---------------------- ------- ---------------------------------- - -- --------- -- ------------------------------ ------------------------------- -- -------- -------- ----------- FinalrEns ection b -- - `� -:-_._ --------- ---- --------------------------------- --------- ate -------- ------------------- ---------`--- p Y . ..., d 2 ' EH 13 24 µ SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M