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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- Permit No..... (Complete in Triplicate) ----------------------------------- ---- -------------- Date Issued__�7l,S"-7J�" ,;. / -------------_---------------------------------------- -- This Permit Expires 1 Year From Date Issued r. :. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the workrF erein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ! 4 GG Met I[a p � /V ------------.CENSUS TRACT----------- -------- JOB ADDRESS/LOCATION ---.- -- ..-'-`� - - - f Owner's Name.--- F(�A.A-(kG M-I-(fee-- - - - - ------ ---------- ---- - -------------Phones_----------------:-- ------------- Jf�� - el, Address-----.1�}�"�' -------------- n -- ------ ---- --- f- --- -. City ---- Zip - Contractor's Name.-=--•--- r&-------------------------------------------------- .-------License # 'ZU � ------'Phone---- .1' Installation will serve: Residence ❑ Apartment-House.❑ -Commercia[ ❑ 'Trailer Court/El F ;.... . • Motel.. = ': C P-f. d( t ' --Other _. umber of.living units:-----( --------Number of bedrooms_G..---Garbage Grinder---A::;)---Lot Size_.___ a'I .R' --------------- /Water ._______________ �WaterSupply. Public System and na a--... ----- ------------------------=------:-;::..--------------------r------- _:. ----------Private �haracter of soil to a depth of 3 fleet: Sana'-5+ -Silt EJ, ❑ Peat E] Sandy Loam ❑ I Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Ma'teria'l............_If yes, type--------------"'---------. (Plot plan, showing size of lot, location of system inkelation to wells, buildings, etc. must be placed on reverse side.) s NEW INSTALLATION: 'jNo�septic tink oF,�seepage pit per fitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ 1 J'SEPTIC TANK [,1 � � Stze---------- -kb_x--7�i'�` ---'- -----------Liquid Depth �lk Capacity-. ----Type Material Compartments------ G1 # Distance.to earest:�WelL_--___w--------- -----------____.___Foundation--_-__ _--_____:______-Prop. Line.__.-._ �.. ' ...- E 1 Y 10 -LEACHING LINE [ ] No. of Lines_ ____.__� )_.-._-- _..Length of each line________�La'-__.___.._---_:Total Length __.,=_`Z ------______. -- :'D' Box----- Type -ilter Material------I -- -- -----Depth/Filter Material------- -------------------------------------------------- .Distant'to Barest: Well_:__:__ V"�__-- -Foundation-------- '______-_---_.Property Line_.____5f'----------------------- { SEEPAGE PET 1 1 Depth___________ ____Diameter.------------------- Umber-----<___------------------------ Rock Filled Yes'.❑ No E] CAl Water Table.Depth .. .. ---.-.---.Rock Size------------------------- -------------------- - --------------------------------- Distance to nearest: Well---------------= - ---- --- ----- Foundation----- Prop. Line REPAIR/ADDITION-(Preva Sanitation Permit#------------------------------ ---------Date----------------------------------------------- Se -•--1 Septic Tank (Specify Requirements)---------_==----- ---- = Disposal Field (Specify Requirements);_..---'..---- ----- ----------------- T -------------------------------------------- = = 1 - -------- ------ ---------------------------------------- -._ -------- ------------------------------------_ -- ------------------- -------------------------- (Draw existing and requirea'addi ion-on reverse-side) Y I hereby certify that'i have prepaid this application and tha the- vork 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 "I certify that in the Ileiiformance-of ,'the woror/which this permit is issued, 1 shall not employ any person in such manner as to become subject to .Workman's,'Compens i � law's oali i rnia."; Signed -- ---------- ------ n f � � i - tom: .-f .� - ----- -------- - --------j----._�'Title� - -------------------- - ------------'------------ . f -(If other than:owne FOR 9EPARTMENT USE ONLY � ' PPLICATION ACCEPTED BY = Y------ --=7 =- - --------------DATE.-- _ ._LS ------------------=---- DIVISION OF LAND NUMBS -- ------ -- - ----------- - ----- -� ---------------.DATE-------------------=-----------------------' -.• i ADDITIONALCOMMENTS--- --- ----------------------------=------:-------------------------- ------------------------ - ------------------------------------------- ------------------- ------------------------------------ -------------------_------------____ '_____.__-_-__r-+^�F_____1,.-----_------------{-------_------------------------------_._____------. _ . ------------- -----------------------;-----------------------____ ._-___. ___ .._ --------------------- __._ ----------------------------- -- --- -------- _--- _ _--_ �r Final.1nspection-by:- ---- ----------------------- ------':__.Date...�`-- ------ - 1,�7 FH 13 24 •~ -SANWJOAQVJ OCAL HEALTH DISTRICT r&'s 21677 Rev. 7176 ann