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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I C ^ `D- --------------------------------------------------------- � � ,t --------------------------------------------------------- (Complete in Triplicate) Permit No. - - ------- -- ------- ----------------------------------------------- . - 3/� /`9 ' Date Issued---------------- --- e _----,-__---,----_-------__.-- This Permit Expires 1 Year From Ddte Issued Application is hereby made to the San Joaquin Local Health District for a permii�tof construct and install the work herein described. This application is made in compliance with County Ordinance No. 549' and existing Rules and Regulations: �..�. .., __.. . - ,. � TRACT.... �.� JOB ADDRESS/LOCATION-.--- 7�f �� 1 ;----------CENSUS --!-- � /---------------- 7 --------- ----- �/�/_�. i Phone--,-?/ 4A. ---- -- ------------ -- ------------------ Owner's Name_-- - •--� --------- -- ------------ ----------- _ . - - q r� = Cit Zip ; Address + ! /: y.0, l = ---- ------ --- -- Y 3 �. 5 7 �f Contractor's Name- - C,-- ctc� C ------- ------------- License # �� Phone -: ;- / $3r3 ... .i. . Installation will serve: Residence 2] Apartment, House ❑ Commercial ❑ Trailer Court ❑ , Motel ❑ her ------ ----------- Number of living.units:-_' -. - -- Nurr&r of,bedrooms ___-- Garbage Grinder ----. ` Lot'Size --/J�� -- { i Water Supply: Public System and name----=----------- ---------------- ---F----- --:.__. -- -------- ea 1- _ - nd Silt -Clay Pe �} _ _ ______ � -Private Character of soil fO' deathof 3 feet: '� Sa 0 ❑ y ❑ at ❑ Sandy Loam ,;Clay Lom [] I - a --.---If YeS,type----------------------- -- ---- t Harcip ❑ , Adobe ❑ Fill Material... 1 , [Plot plan, showing size of lot, lo of system in relation to wells, buildings, etc. must be placed on reverse side.)1. NEW INSTALLATION."' [No' septic f n mo�r seepage pit permitted if public sewer is available within 200 feet,) I PACKAGE TREATMENT [ ] SEPTIC TANK,(] Size------------ - ------ ---- Liquid Depth---------------------- -------- -------.------------- Q Capacity------------ Peal= _ ,Material = 'r No. Compartments 1 t Distance:to nearest:.Well �`-----=------Foundatiori�_--.----=----- ------------ -- = .Prop. Line ^ - { t Total Length.i ----- -------- LEACHING LINE_- [J. No. of Lines_ Leng#h of each line---- _--.- - D Box--:-- Type Filter Material �._ -------Depth F`ilt-Materia _ L ----- -- -Distance to nearest: Weli----------------------------Foundation---------- -------------�\�.property Line------------- - - t ,y. s Rork Filled Yes ❑ No SEEPAGE PIT [ ] p ---- _ __ umber_-- Rock Siz � � i - -------------------- -------------- . Depth DiameterN ='r`�,---- ------------- p / Water TableDe th--- - --------------- ---- -- ---------� e I ] Fp E Distance to'nearest: Well.-.-'- --------- - ---------Foundation----1-- -------Pr Line REPAIR/AD { I --------------------- REPAIR/ADDITION (Prev.(Prey: Sanitation Permit# -------- Date-.-.. --- - ------] fl _' = -------'-------- -'---- Septic Tank.(Specify Requirements)---- ---------- --------------- - ----------------- # s r , !ice j Dispose! Field [Specify.Req uirements]----._,;-------------- ---------- -- �- i --------- -- ----------- - - ------ --- -------- ---. ------------- -- ------------------ ---------------------- -------- ----------------- ---- --- --------- ------ --------------- k ------- - -- - -------------------- - - (Drawexisting and required addition on reverse side) I hereby certify that-I -have prepared this application and that the work will be done in accordance lsth�icin_ oaquin.County Ordinances,: State Laws, and Rules'and "Regulations of the San Joaquin Local Health Distri f'Home ownsor. incensed agents g sinature certifies the following: .t f } - "I certify that in the performance-of_ the•work for which this permit is issued asl hh R not employ any personinsuch manner`as I to become subject orktnan's ompensation laws of California.".- i + + „ t.= Signed------------- --=---------- -------------------------------•----- -- Owner. -, ---0 er _- ----- - ` -------- ----------------------- Title----------- - (iIf other than-owner) , ' s , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-. DATE_ J - < --------a DIVISION OF LAND NUMBER ------------------ -- - _ DAT E _ ADDITIONALCOMMENTS ----= -------:---- -------------------=---= ------------ ------------------------------------------- ---------------- ---- ---------------------- ------------ --------------I---------------------- - - - - ----------------------------------------- ----------- Final Inspection b - ------------------------------------Date 4/- EH 13 sa / SAN JOAQUIN LOCAL HEALTH DISTRICT 2 677 REV. 7/76 3M