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t x FOR OFFICE USE: FOR OFFICE,USE: APPLICATION FOR SANITATION PERMIT {' Permit No"- ---7 - -- --- -- --- ---- , ------------------ x � � (Complete in Triplicate] --------------- - - -„------------ ...,�„ Date issued---1 '---- --'-- r This Permit Expires.1 Year From Date.lssued• - ------ _---- ---- =a I r .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 existing Rules and Regulations:--- , f.�. --a-a� _---. ` . . CENSUS.T'RACT----------------- JOB ADDRESS/LOCATION __- - - _ � ,., Phone._�1�.� Owner's Name-:_- � f --- i ------- -------------------------- Address-- Zip /,� Phone ` Contractor's Name ----- _. - ' Installation will serve: Residence Apartment House[] Commercial ❑ Trailer Court ❑ rt. :... ...t ,. ''Motel�❑ .. Other___ -- --------------------- Number -- ----Number of living units:_._-_L _____Number of bedrooms-_-9--_—Garbage Grinder-------- _Lot Size------------------------- ---- ------------------------ Privafi r,. , Water Supply: Public System and:name _ : ---- :------- --- ----------- -`- ; Private 'Character of soil to a depth of 3 feet:. Sand ❑ Silt E] Clay [] Peat Sandy Loam E'] Clay Loam E] Fill Material ---If es, tYPe `f Hardpan❑ i Adobe , Y {Plot plan, showing size.of lot, location of. system'-in relation to wells, buildiAgs,`etc. must be ,placed on reverse side.} NEW INSTALLATION: .(No'se tic`.tank or see a a it ermitted if public sewer is available within 200 feet,) ' p p 9 P p i ' Size-------------------------------------------------------- ,A. - - �...�....�..•--Li --------------------------- PACKAGE --------------'= --- -------- 4 quid Depth PACKAGE TREATMENT '[ ) i'SEPTIC TANK.[ ] � { ------�---- ---- - •` k Capacity:-:.---i= TYPe' = "=`="-Material_--- aVp = n No. Compartments Line 4 _ ..,.r. — Distance'to nearest.:-Well-------- ------ -----=--- ---:__..F. clatio ------------------------ o - { € f Len each.line, ,' =, Total .Length -------- ------------- ------------------ LEACHING [ LINE [:l No. of Lines ------ :.,,: 9th of eac - �. D Box.-------'---Type Filter Material-' --------- -----Depth Filter Material-------------------'------ i Distance to ----- --Foundi Foundation---- .Dish nearest. Well �-------'-- ->-- --- ----Property Line----------------------------------- ------- ------=----- ---------- l. ... • •wa i „ - SEEPAGE PIT [ j P ---------..`----Diameter--------------- e. --- ----- ---.Number------------i :-- Rock Filed Yes ❑ No ❑ . Depth :Depth Rock'Si�a _, - - ----- Water Table -- ---- ---- --- --- .. -— Distdrice to nearesf: Well."'"` '-� Foundation_ ______________ "_.Prop. Line_-__..____________ s ----- --- ) REPAIR/ADDITION (Prev. Sanitation Permit#--- --•----------•--=-- .-- -- _ ---------- ----------- - P Y q € ___� 1 . :Date _ - - :_' ' r ------------------------------------- Septic � Tank (S ecif :Re uirerrlents)--= � .s L .' = :.:: Disposal Field.(Specify Requirements)._--_ - �� ---- ---�"-------- - I I. - ---- --------------------------------------- t ------ ----- - =--- ------------------ ---------wired--a--d--d--i---o------------------------ ddi ={ _' + __ ____ _ _ __ 3 (Draw existing and req tion•On reverse side) C I hereby certify-that'l -have prepared this application -and that.tlie 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 fhe following: "I certify that in 'the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become bj t to Wol. an' [,Compensation. laws of California." - - as' _ � ---OWne•r Signed_. ----- --- ---- _ . . t - -•_Title-- R -------- -'--- ------------------ ------------------------------ k f '(If ofer than owner) FOR DEPARTMENT USE ONLY 4, 10 lor ' - -- ----- -------- --- -- APPLICATION ACCEPTED DATE .� -- - ----------- DIVISION - -- - DIVISION OF LAND NUMBER-------:----------------- - - PATE__-: € �l ADDITIONAL COMMENTS.--------------------- ----------- ----------- - 4 . -� , . - ...----------------------------------------------- --- -------------------- ----------------------------------------- ---- --------------------- --------- ---- '--------- = ------------------ ---- ----------------------------- ------------------------------------------------ - ----------- --------- --------------- ---------- ------'- � --- --_1._-G ---Date-, �-'3_.7�----- ---'-----' .. Final inspection b :__ - _ —��• r&S 21677 REV. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT