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,.6-FORIOFFICE-USE: _ FOR OFFICE USE: APPLICATION FOR-SANITATION PERMIT - 7 _ _. Permit No.-- - -- ---' --------- -------------- ------ ' = -------------------------- ---- Tomplete in Triplicate] Date :V," ued : , ----------------------------------------- Issued_ -------------- -- --- -- pate lis This Permit'Expires 14Year Frons Date:lssued � Application is hereby made to the San Joaquin Local Health District for a permit to construct andinstallthe work herein described. ) pliance with County Ordinance No. 549 and existing Rules and Regulations- This egulaati°ns: This application is made in com r {� v v r L CENSUS TRACT._-F----------------------_----- _ ------ = ------------- ----------------- JOB ADDRESS/LO ION.__.; -_ 0-��-� ph - -- -. ---- - Owner s Name-'----_- - --- - ---- _ _ ..; .. l --------------- Address - -------- Cp Zip _ _. _ __ �k�'---- -- ---- --- ----- --city � - - Address-------------- --- -------- ---- ? �G ' - � --�-•-- -License #-�-�l�.tY.Sf -Phone.��--- ------�- -- Contractor's Name ' �. .._. i. tallationwill serve: Residence Apartment/Hause ❑ ]Comercial ❑ Trailer Court ri Ins' Other- -- - t Size- ' Garbage Grinder -_.- _-_ Lot:S Number of Diving units:--- ------Number of bedrooms;.- P f ! ' = nva to .�} Water Supply: Public System and1namef7---- ------- -- = Silt C'la. Peat [� Sandy Loam ❑ Clay Loam ❑ Character of soil to a depth of 3 feet: 5arad ❑ ❑ i�Y ❑ Ifes, type-------------------------------- 101 ------- -------- ---- ---- r"'il �°Hardpan ❑ Adobe F�I� Material._- .- t y I yp 101 (Plot pl&"n, showing size of lot, soy ation of sysi m-in r0ation to,wells, bu ildih gs,.etc, must be placed on reverse side.) �y NEW INSTALLATION: (No septic tank -or seepage it permitted 1f public sewer is available vwi#hin 200 feet,] t - _"Li uid Depth._-------------------------- PACKAGE TREATMENT [ 1 SEPTIC TANK I l Size.__---------t ---- q _ T t 6 "' Ca acit j ,. . e- Material--- ------ --- --------"No. Compartments.- ........ 1 11 .Distt6nce!to nearest: Well.- =---=----- =--- -------lFoundation.._-- ------------------Prop. Line_:_----------- r r !, f ; -------------- Length of each-li _ .-_ -- ---------------.: otal,_Lerigth LEACHING LINE 'l No. �of•Li'nes - -• -- k - : p '-- -------------------------------------- :'D' -- --- -- -- Type Filter Material __ --_.-De t----------- Filter Material .' D' Box �_ ,. - --. -}- ---- --._ _: ..Fou dation------------------------=---Property Line- - --- - -- 9 Distance to nearest: Well-----------_ .__- --- _ ] led Ye ❑ . i Depth Diameter. Nurnber_ E�-`."----- -- F Rock Filled s No SEEPAGE P17 [ 1 p, ,.. . .R coco kti5ize - - --- --- -- - -- } Water Table Depth -= ; ( ¢ ..Distance to nearest: Well- _ - - - - !Foundaatiari. Prop. Line---- -- f �? ] " " '. = i ----ate-- -- --`$ - - REPAIR/ADDITION (Prev. Sanitataon Permit# --- --- -- I -------------- Self is Tank (Spec ify„Requ ire ments]i----------- h1 Disposal Field {SpecifyeRequireme;ts]_.,__-. 1�”' = r` - -- ----------- ------------ �c ..per. z e , ( _ __ _ _ # I 1 -------------------- --------- t - g q (Draw existing and required additi n#on reverse side) ' I hereby certify that. 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 Loca�I�,Health District, Home owner or licensed agents signature certifies the following: - 1 I 1 1 "I Certify that in the pe�rformce of'the,work for which this permit isssryed, I shall not employ any person in such manneras i -- p lifornia. .- to become b' ct t orkm n`Com ensafiion laws of Ca r ' I '� Owner " -- s Signed.- ; ----- - - ----- - (If other han.owner) - FOR DEPARTMENT USE ONLY ' -DATE1 a ��-- - --------- APPLICATION --- -- APPLICATIONACEPTDBY ------------------------------------ ------- �-- . DATE------------------ DIVISION OF LAND NUMBER: --- = ------------ j r - - I ADDITIONAL COMMENTS--- --------- ----------------------------------------- ---t = --------- ---------- ------ -- - ----- - ------------ ------------- --- --------- __ - - - = 1 t . 1 --- - -------- ---------- -�---- •--- ate --- --- -- -- ---�" f Final 1ns-wction 6 ""_4` __- ° ------ ------ r 31)1 p Y"'--- --- - -�- - � F&S 21677 REV. 7/76 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r F