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FOR OFFICE USEa FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No7/ (� __4-:- (Complete in Triplicate) ------- ---------- ---------- ------------------------- Date Issu�o(fe---.,�- --�1 This Permit EyxS�,p,�ires� 1 Year From Date Issued +_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descri ed. Ordiriance No. 549 and existing Rules and Regulations This application is made in compliance with County _ t ! ------ .CENSUS TRACT- ------------ ----- ----- JOB ADDRESS/LOCATIO --_ -------- Inhone -------- ------------------- ::. P' ---- --- ----- --- -Owner's Name._ y' city.- zip----Address- -, 6P Contractor's Name I License # 1 __Phone. t a. Installation will serve: Residence iApartment'�Hiise❑ Commercial ❑ Trailer Court [:1 a t• .. Mo I ❑ Other_ --- - - -t --------------------------- Number of living units: ___-_ Number'of bedeoa ---Garbage Gunder_-----------Lot;fiize.._> _ {_ v __ Water Supply: Public System and:name ---------- I_ _ -�1 la Loa } _ P ___,.P�'i at Character to aepth of 3 feet: Sand '. lL'In: i Silt ❑ Clay ❑ Pet ❑ Sandy Loam ❑ Clay 0 !r^,.. 'Hardpan [} ,�dobe� Fill Material---- If Ye's,type --.-- =-}. _ j (Plot plan, showing size of lot, location of system in relation to wells, buildings etc ,must be.placed on reverse side.) NEW-•INST•ALLATION�,�(No-septic—tank or Zeepage pit permitted if public sewe`r�isayailabl�a within 200 feet,! ii Depth--------------------------- PACKAGE ------ ----------- - Size_ y PACKAGE TREATMENT ['•:],`r"S-fPTIC.TANK'[� --- - ---- ---- ----- ------- e- �l.'qu•d Material " ::No: Compartments --------' —Capacity Type------------------- f i - _.Foundation '_ ----- ------- ----------- Lim ne, -_ ; Distance-totel - G LEACHING LINE t ] -ti No. of Lines-s. - _ -_-' ._:_- . .Length of each line, -----------------------------To Length -__ 1 D' Box ---- -Type Filter Material__. --- Depth Filter Material-------- --- ---- ---- Distance to nearest: Well_`��------_..- -----------Foundation--___--__--______---_,_ Property Line---- �y t ....... ._ k Filled Yes ❑ No QS f, - i ,,. f SEEPAGE PIT j ] Depth---- -----------Diameter-_- Number Roc Li-.. Water Table Depth... _-____ -------- ----=------ -- A -'Rock .Size------------------------------------------------- � & Distance to nearest: Well_'-____ J };t ] d ;_ " . Foundation__. -r---------.Prop. Line -------- ------------ -- i REPAIR/ADDITION (Prev, Sanitation Permit#___.-_ _'-"--'----------------- = Date! ---------- -------- - ) Septic Tank (Specify Requirements} Disposal Fiel ecify Requirements)__:41 r --- �� '� �r ''---------- ------ -- ----------------- ------------------- �- ; n. Draw----istir- and -- wired addition on revside) ----- -------------------- { g q reverse K 1 hereby certify that i have prepared this application and that the work will be-'*xie-in ccordance with San Joaquin County Y Y P P ^`° Y " Ordinances, State Laws: and Rules and Regulations of the SanjoaquifrLocal Health District, Home owner or.licensed agents signature certifies the following: F `, [ertify that in the" rformarice of the work for which this permit is issued, I shall not employ any person in such manneras } t become ubject to . kman s Co tio�r laws f California." i` Signed ` '. _ Title ( � � - --•� (If other thari�'owrier) �FOR'DEPARTMENT LISE ONLY! - APPLICATION ACCEPTED BY----- -- -------------- ------- ---- DATE _/6-- -/_'77---------- -- -------- APPLICATION DIVISIONOF LAND NUMBER:-------. ------------------ --------------------------------- ---------------- --. : DATE ADDITIONAL COMMENTS-------------- ------ ------- - ----------------------------------------------------------------- -------------- ---------- ----------------- =. ------- -- ---- ----------------------- -------------------•---- ----------- -„ ---------------- -------- ----------------------------------------- ---- - -- Dt - I A -_.._. _. . .®.. ------ a e--- ------------- - ----------------- - Finan Inspection.b ^- =----�-- �t-.�. -�----`-- ----------------------- �--------- -- � "' -- --- -- Y ---"- "---- - - -- - " F&5 21677 REV. 7/76.3M EH 13 24 - SAN JOAQUIN LOCAL HEALTH DISTRICT