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FORT OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ' Permit No... - �-----'----- -' ------------ ------ ' -- --------- (Complete in Triplicate) =• t - ------------ ---- Date Issued--.'F=r56J7-- .-------------------- ------ _..-__-"" n This Permit Expires 1 Year From Date Issued r . Application is hereby made to the San Joaquin Local Health District for a perit to,construct and install the work herein described. m This application is made in c mp 'ante wit unty Ordinance No. 549 and existing Rules and R gulag — ��j - CENSUS TRACT---- =-----=•- -'-- -'- -- JOB �DI�E55/L CATION_.: : € -'-----------=--- Owner's No °---------------- ----------- --- -- -_----------- e ---- --------- --------- city-. ---- -- " Pon :: - •- - -- - ¢ 47- ' C �' P Address ' / =s itY- h Z� € 07 - �.. License - one---------------------- ' .; e # �a�-, P Contractor s Name.__._- _"---------�-- - -a•- - Installation ,will serve: Residence �.. Apartment House.❑ Commerci I Trailer Court El • • `VMotel ❑ Other_- �Y� 1`-rrz � --- i = v ` s _Lot. Size__4 Number.of livingunits:.__.-__.L_._"_Number of_bedrooms;-_.----."_.Garbo a Grinder_._..-__-- Private 'P — — ' g '' ------ Water Sup Public Sys#em and name___.=-""---------- -- -- `.,.: ' --=--_--'-------------------- ------------- - -fl ❑ .y _ Peat Sand Loam Clay Loam ❑ Character of soil to a depth of 3 feet:`Sand •�-Silt Cla. _❑ ,� [] Y ❑. . i an [✓�f Adobe-❑ -Fill Material. ---- __If yes, type-------------------------- HardP [Plot plan, showing size of lot, location_of�systl ir-relation`to'wells, buildings, e`tc must be placed on rev�*rse side.] NEW INSTALLATION: (No septic tank orseepage pit permitted if public sewer is available withinlg200 feet,) PACKAGE TREATMENT-[ ] ' SEPTIC TANK- [�] . Size-.,--r -- `------•--.--- -------- -- --------------L' u'd Depth--------------------'---- 1. `1 . ' - - - - r m -- al _ --- -- -- -------- . ents CaPacitY = Type Matei ' ' - -- Distance;to n --•----Foundation-------=-------------- -Prop. Line.----------------'----- , + earest: Well ' 1-------- -_Total LEACHING LINE_ .[ ] No-' of-Lines" Length of each line '_ .__ ___y._ - o a Length.:-._ D' ox v�._ Type Filter Material____ __ ____ Depth Filter Material--------------- --- - -------------------------------------- B ,. ------ --Distance:-to nearest: Well-----------------------------Foundation Property Line.--------------------------- _., -. - -- N be.....� Filled SEEPAGE PIT [ ] ."Depth.'---' -`----Diameter r "� ' ' Rock ' lecl Yes ❑ Na,❑ Table Depth.--: __ Rock Size --------------------------------- Water ' ; -. " Foundation Line--------------- --------- ------ ---- --- , Distance to nearest: Well'_'-_ ' --T�-------------------- -- -.Date "--: --- ----------------------------- ------------------ -- --------= REPAIR/ADDITION (Prev,Sanitation Permit#_.-__.__.___ ,__ '- --------------------- -------- --=_---- -- -- -------- Septic Tank (Specify Requirements)- = --- - `•' Disposol Field (Specify Requirements)_ -._ -- r 3 U - -`- -- -------------- --- - --- - �L �. -------- .. --------------- -------- --- ; - (Draw existing'ancl required addition on reverse side) �I I hereby certify that l have prepared this-application and that the-work will be done in accordance with San Joaquin County s of;the, San Joaquin Local Health District. Home owner or licensed agents I Ordinances, State Laws, and Rules .and Regulation signature certifies the following: l 1. "1 certify that in the performance of'the work for wfrich'this permit is issued,'] shall not employ any person in such manner as ,F to become subject to Workman's" Compensation laws of California." r Signed- ------------- -------- ----------------- -----------' ;_ _.f _.Owner_. .: r. ... Title (�`^!�•��' f {1.f'other'than .own r :v lfpR.DEP TMENT USE ONLY c _ fi -- - D APPLICATION ACCEPTED BY_, --_ -" -- -- .. ATE ------- D1VISION OF LAND NUMBER---------: " ----------------- ----- --- -' -' [ ADDITIONAL COMMENTS----.------------- ------- ' ----- -------------- --------------- ------------- r ! - ----------------------------- ----- ---------------------------------- --------- ------------ ' -------- - 9 - _.__._.___ -__.__________________________________________.`..__.-_.. _- --------------- ---------- -------- Date-- r - - - _--_.____ _ ------------------. Date- - _ Final Inspection b ---- `= 1 1 p Y�=--�-' ' --'"" F85 21677 REV. 7/76 3m H 13 24 SAN OAQUIN LOCAL HEALTH DISTRICT E "