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FOR OFFICE{USE: y d s..„« _ ------------- APPLICATION FOR SANITATION PERMIT ---------------------------------------------- -°`� FOR OFFICE USE: (Complete in Triplicate) - " �\ \� Permit No -- ---- ---------------- - ------------------ -- \ ,f z This Permit Expires I Year From D v '� Application is hereby made to#the_San Joaquin Local Heal ate Issued - -•�` Date'I'ssued_-_ �- This application is made in cpm liance with Count Ordinance No. 549 and �1 r � _ P Health District for a permit to construct >� �µ Y and install the work herein described. JOB ADDRESS/LOCATIO existing Rules and Regulations: e � 7 e � Owner's Name. --: - ' t / _ . __ ----------- _ 4i_�- - - --�---- Address - ------ --- --- ----- i - CENSUS;�TRAC�s 1_l _ / ,�J , ------ Contractor's Name-- -------- - �- --- --------------- ----- - tY -�-- one Installation will. '' =_license #_ ---- -� . zip• -- -- serve: Residence.�,,�p : 1� H artMont House. . .�. .� ❑ --Commercial � _ - -- -- --- -- -- � Number of liv.in Motel ❑ ether-.. ❑ Trailer Court ❑ g knits:___" _'�---Number.of.bedrooms _-- ---------- W - -- f Water Su 1 = r- Garbage Grinder �` ``` Lot PP Y: public System_ and Warne._ `* Sizey '\ -----:.:--------- ------ - ' ----------- _ Character of soil to a depth of 3 feet x "--" Sand ----- ------------ '� � ❑ Silt -- --:--------s------- Hardpan - '- ---- - • ❑ Clay❑ Peat ,_Private ❑ Adobe ❑ Sandy Loam Clay Loam Fill Material__- "_-__-if es, t (Plot Ion Y typeEl El Fill , showing size of lot, location of system in relation to wells, buildings, etc. must be ! 1 NEW lNSTALLAZION: `(No;septic tank`or seepage it Placed on reverse`s de.} •� PACKAGE TREATMENT ►- P permitted if public sewer is available within 200 feet,}: l [ ] SEPTIC TANK [� r • r J Size Capacity l� --- X 4 � rj - P Y -� 19fl._. eTYPe a �iquid Depth. _ _�- , k ----Mataro .Distance to nearest; Well_____-_---_"S'b - - _ LEACHING LINE: _ . _1 P rt s- ----------------- - --------- Foundation (Q om L a mt [ k--No. of Lines "-- i ----.Prop. Line-` " # r g each line.__I _ 6 -- ---------- ------------------ Len 'th of ' D' I3ox r ' -. � �(Qi-If Total L � .J8,.._Type;Filter Materia _ -. -De t :. g g , l f_ ---- ---- Length I -�" i - _:. 1 " i � r r P - Filter Material__=___-"_�_ ` Distance to nearest:•We11__ ---- ------- - .PIT :F. J . Foundation - '�-- - ,• - ------------------ SEEPAGE- � _ ur [ Depth.___'--Z n-D,iameter-w._-_ �Q r -'---.Property Line__ _._J_-"_" " a ,.Num r_--- _ _ - be a f x k Water Table be'pth-_"`-- 1�- k - -. _ . . Rock Filled Yes+��No❑ - - i 1 - Y Rock Size:_.- L k_j__"t _Distanceao nearest: Well:_ �l90 r- ----------------- - ---------------- --------------Foundcition----/ J . Prop. Line_ J REPAIR/A°DDITIOW(Prev. Sanitation Permit#_ 'r,_-"- ______----- _________F_�_ X • ___ Septic Tank (Specify Requiremntsl' �_- _ C ate.__-__-- ,, } ------ --------- a- 0 -- '----------------------------- ---------------- --------------- -=----------= --- Disposal Field (Specify R quirt merits} � ' ; - f -- e 1 - 3 -- ---------- --------------- ------ ----------- rh. x -�------------ -- ---------------------- ----------------------- -- -- --- •---- - ------------------------ ---------- ------------ ---- .:� --------------------- 1 _ ------------------------------------ ^ 5. - --- .---------- ---- --- --- (Draw existing and required addition fon reverse side) l _ � I herebycertify that-I have prepared this application and that the-,work will be done in accordance with San Joaquin Ordinances; p p ' State-L•gws;'.and-.,Rules and Regulations .of-••the.:SanR q q County � signature certifies the following: _ baa uisi Local Health District, Home owner or licensed agents All certrfy-thdt'in'the '= to 1 performance of the;work for which this permit is issued, I shall'not'em _ to become subject to Workman's Compensation .laws of California." p y an Y person in such manner"asSigned-- ------- ---------- ----- ' Owner - 1 BY- -------- : . . . . -- --- ----�----- ---- -�- ------------ ._-Title --- -- --- 1 (If ofher than owner �"" ' ;FOR DEPART ENT USE ONLY r h-- 1PPLICATION ACCEPTED BY------------x--- - , _ S." )IVISION OF LAND NUMBER ` = .DATE. ........... --- TIONAL COMMENTS-- ------------- ---- -- i -- - ----- --- -- -------'---=---------• -- -------------------------------------- ------ ------------- ----- ---------- -- ----- - ---------- -------- ----- - ----- - ----------- 3 --------------- ---- ---- --------------- inal Inspection b ------------------------ ----- _ Y ---- ---- ------ ---------------------- i3 24 -- ----------- --Date_" - "-" ---- ----------- JOAQUIN LOCAL HEALTH DISTRICT -----"-- FSS 21677 REV. 7/76 3M