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'FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 7?—//'/ --'- ---------------------------------------- (Complete in Triplicate) --------------------------------------------------- 1 w I.".- _ _ Date lssued_.�._:�_,-��- i ------------------------------ ---- Thi's Permit Expires 1 Year From,Date Issued i Application is hereby made to the San Joaquin Local Health Distr. w ict-for a permit to construct and install'the ork liereir described. This application is made in compliance with County Ordinance No. 549 andexisting Rules and Regulations: _ . . 'CENSUS TRACT--- I_ -------- ---------- JOB ADDRESS/LOCATION ------ ---------- --- qF / Pone----- - ----- -= - Owner's Name G / /L/-,� SA -- ---------- -------------�--------------- l- � ` = City `'' p - �5 ----------------------- AddressZ i Contractor's Name------ �L ----------- --------- -- -- ---- ---------=------ ------- -------License,#----_------ .. --- ------- oilPhone Installation will serve: Residence ❑ Apartment House.0 Commercial ® Trailer Court ❑ Motel ❑ Other_. / t:. % t Number of living units_________________Number of bedrooms____.-_______Garbage Grinder_.__;..___--lot Size_ - -...- - - • i . Water Supply: Public System and name--------------- --------- ------- - ------------------------- ---------- - .. . .., r-------- --------- Character -------Character of soil to a-depth of 3 feet: Sand Z Silt❑ 'Clay ❑ Peat ❑ Sandy Loam E] -Clay Loam ❑; : Hardpan ❑ Ado Fill Materia L..__.__.___If yes, type________________{______-___-- 1 ' l [Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse'siae-] NEW INSTALLATION: (No septic tank or seepage pit permitted if public seweris av ilable within 200 feet,) , SEPTIC TANK Size-- ` ____ __----- - iLiquid Depi ------------------ PACKAGE TREATMENT [ ] _ Ca actY ��190 - YPe0F�- Xat&rial---- mpartments------�---------------------- - -----e -- / . a � _-Distance to nearest: - _ � -____'_.__ .V- y of-each. a Total Length LINE No. of Lines.:._ ength lin ` ____-"-____3___- . . ,. 'D' Box----/...__Type Filter Material-_t__ ------------ th Filter Material_-------!-____ --------___------------------- � Distance to nearest: Well------------------------_ __ Fun'dation____------ .______. o� ---------Property Line---------- - -` --------,- f". '—� Rock-Filled tiYes ❑ { No❑_0 SEEPAGE PIT Depth th____.___-: --Diameter--------- -----------Number'------___= ----------------- - .-- - � E ] Water Table De th----------=----- --------- --- - ``----------------Rock Size------------------------------- - Distance,to nearesf: Well-------------------------------------`----Foundation--------- ------.Prop. Line------------ ` REPAIR/ADDITION (Prev. Sanitation Permit#----------------------=------- ------ .Date'------------ -------------------------------) Septic Tank (Specify Requirements)-=----==---------------------------------- ---'------ ----------- ``` --------=----------------------------- k Disposal Field (Specify Requirements)----------------------- 4 -------------- -- i I ---------------------------------- ---------------------------------- ------ --- -------------------------------------- ------ -------- - - ---- -- ---- ----- ----- ----- -----_______________�_..____----__-_.____._____ ____________.______.__.--_-__________-_-_______..__...._--_________.______.___. _ - - _. _------------------------------ (Draw existing and required addition on reverse side) n hereby certify that I have prepared this application and that 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 performance of the work for which this permit is issued, 1 shall not employ any person'liwsuch manner as to become rsu . ii � . pensation aw ' _ G Signed------ - -- -- OwnEw BY r i : Title--- =----------------- ----------------- --------(lf other than'--- :-----•-- -------------- � - :owner) : . FOR DEPA TMEN�USE'ONLY I' APPLICATION ACCENTED BY=-i --- - --- ----- - -- ---- - -- DATE. -- DATE-------------------_-------------- DIVISION OF LAND NUMBER--------------- -----------------------------.-------------------------------------------------------- ----------- 1 ADDITIONAL• COMMENTS---------------------------- --- ---------------------------------------- ----- ---------------------------- --------------------------------- ----------------- ------------------------------ -------------------------------------- ---- ----------- ---------------- t - ___----------------------------- w'�-'- ------ ----- -----------------------`-------------------------------------------------------------- -- --------------. --------- . Final Inspection by: -=--- Date.:._ �. -7.7------------------------ EH 13 24 SAWJOAQUIN LOCAL HEALTH DISTRICT F&s 2107 REV. 7/76 Sea