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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No._.i��r_ ...... " ' {Complete in Triplicate) Date Issued. - '----_7`"----� -------------------------------------------------------- This Permit Expires'l Year From Date Issued S .2 G `75 �7 Application is hereby m'ode 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 N . 549 and existing Rules and Regulations: 5 = .. _ . .. .... x Y . JOB ADDRESS/LOC TION _------.---,�tJ ¢` � � CENSUS TRACT---------------------- Owner's Name y i Ph e i Address. �/�.- - -- city +.1. i`4.c5 3-� Contractor's Name______ _. ty -------- -- - ----- --- - -----.License # .C'7� '-� ...Phone '�/ •� �/ ? Installation.will serve: _ Residence �. Apartment House ❑ Commercial ❑ Trailer Court; ❑ F -MotelOther, i' � G ---- _ -----_ - Numbe�,of living units:---- Number-o#bedrooms.. r ar - bage Grinder -------- Lot Size L f:=------- - q Water Supply: Public S stem and'name.r..`... . . - Private_ - - I - Character of soil to a depth of 3 feet: Sand ❑ Silt❑ -Clay ❑, Peat E] Sandy Loom-0 Clay Loam ► i Hardpan ❑ Adobe ❑ Fill Material._._ ------If yes, type-----------h.................: s {Plat plan, showing size of lot, location of system in relation to wells._ uildings, etc. must be placed on reverse side.) `" 6 �,NEW INSTALLATION:' (No:septic tank -or seepage 'pitpermitted if publ�c sewer is available within 200 feet,j 4N 'PACKAGE TREATMENT" [ ] "i SEPTIC TANK " Size=--!l_� _=t _- ----------_----Liquid Depth..7__. r.,---------� x , Ca acit / p y.1C .... 1TYPe_ ; ---Material_-.- /_ _ T No. Co artments-.------- t ;, - = —Distance Well D _.s .-.1Foundahon 1 "Prop. Line.-,;) l � . LEACHING LINE. [ No.,,of.Lines __---c _ Length of each line_ __,_:' - .....Total Length. ./7Q-- ------- ---------- D' Box--- ._Type Filter Material_$ .Depth Filter Material.... --------------------------------_________________f SEEPAGE :Distance to nearest: Well-.., Foundation____',,1/4 '_...Property Line..._ -_:. E PIT [`f Depth. ---------Diae�e er. urn er . .. _ j C-T, _ �. Rock Filled Yeso No _ Water Tabie:Depth r Foundation :. ------------------------------ Di ---- ---- --= ----- U = Rock Size Distanceao nearest: Well.:". Q...._ __-_'"".... dation.:_.._/ Q=..:_____.Prop. Line..__ _+ ' a REPAIR/ADDITION (Prev. Sanitation Permit#. ...:..:........' _ __:._..:_'Date.-...;______. --------------------------------) 7" Septic Tank (Specify Requirements)- ------ i' _ ;...,.. Disposal Field jSpecify Requirements)- ----- l -------------- ----------------------------------- ------ ----------------------------------------------- --------------------------- ---------------------- ------=------------------ -------------=---- ------------------------- --- ----- -------- ---- ------------------------- -- --- ----------- --- - (Draw existing and-required addition on reverse side) 1 hereby certify that.l 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 thatin the performance of the work for which this permit is issued, I shall not employ any person in such manner las togbeco nsu e b'ec tor�d-rkan's Com ensotion- laws 'Of .California." . . ne I BY ----" -------------- --- --- - .- ..r. -K----- ----- ------Title--- • ' (If other'the er) , EPAR USE NCY APPLICATION ACCEPTED BY -- -- --- ------ -- ----------- ------ --------- -----`--�i!/, DATE---- DIVISION Zy-:DIVISION OF LAND NUMBE ----- =-------------.-------- -------- -------------- ------------------------- :---------.DATE.--------- ---- ADDITIONALCOMMENTS ------------- ------------=---------------"--- ------------------------------------------------------ --------------------------------- ------------------- -----------------------'----- --------------=------- -------------------------------=" = ----------------------------------------------- i"_ -- --------------------------------------------- •--- - ----- --- - ------------- ------------------------------- - ------------------------------- ------------------ ------------ ----------- ---- ---------------- -- ----------- ---- - - --— -------------------------------------------------- 97 ------------------------------------"------ -- �2 t. Final Inspection by:.-._-_.- -. ___Date-----= _ __.____ '`" _ ' " EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 sM