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' + FOR OFFICE USE: FOR OFFICE-USE: APPLICATION FOR SANITATION PERMIT 5 3 P (Complete in Triplicate) Permit No.._7____'___. -_-- --------------------------- --------------------------- -0 ? Date Issued---0- 3_._.____7 --------------------------------------------------------- This Permit Expires I Year From Date Issued t Application is hereby made 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 No. 549 and existing Rules and Regulations: , ... � ----/-- -----1--- -----CENSUS TRACT------ , ! JOB ADDRESS/LOCATION..__ --- ---- - --------------- Owner's Name------4:2i-°--._ .. - '1'---------- ------ ------------ ---------Phone----- ----;-------------------------- -- ---------- ------------ 2� ..---------------- • - City - zipAddress.__ _ r Contractor's Name-___._ _ -'-_- - ----=---------------------License #-_> _7Phone__' lP _- .---- Installation will serve: ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ s 4 t •. }. A- -•�.-Motel Other- -------- ---------- -I- ---------- Number-of-be ------- T Y _Number_af_be o❑ms'-1�__Gjarlaa e_Gr.index ��_Lot.Size_. --(--.------------------------------------ -- � �. ll 4 Number of living units:_;__- ._-!-____ _ , Water Supply: Public Systemand name ---.C.i-'.__::---:fir ------------ -------------------------- Private ❑ r ri I Chbracter of soil to a depth off' 3 feet: Sand ❑ Silt❑ Clay E] ` Peat E] Sandy Loam E] Clay Loam E] 's ` ;Harpan ❑ Adobe7_7- Fi1-I Material__._f.._.If yes, type------------------------------ c .r.� (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION. [No• septic tpnk or seep6ge �pitYpermitted if public sewer is available within 200feet,) r PACKAGE TREATMENT ;[ ) SEPTIC TANK [ ] Size --------- -------- _----- ------ LiquidDepth"--------- ------_----:--- :Capacity T e Material- ^ _._ ` _:__a----- -_No. Compartments_.=--------------- ___________ r ._ ,Distance--to-nearest:.-Well--- -' ----=----- Foundation `,.r.�. _-- _..Prop. Line ; LEACHING LINE [ ] No..,of Lines-----------------------f: Length_of-each line.--------.----- -----.Total Length---------------_------------------------ Z a -- -_--Type Fil a-'Material - ------Depth Filter Material ------ :-- ------ -------- - ! I ..} ..p _ ; ---------------------- - - Di stance to nearest:WelJI_ " _____._.__.Foundation.__ Property Line-_.____. SEEPAGE PIT [ ] Dept .... _ Diameter_.___ "Numb r. f- F _ Rock Filled Yes❑ No ❑ .� r5 - E .___ ., .Rock S. e ', F I ;Water Table;Depth--- ----------------------------------------- ---------- a . .. -- Pro 1Distance to nearest: Well_ _ --- ------ -- ------------------- Foundation.---------------------- p. Line- -------------------- REPAIR/ADDITION {Prey Sanitation Permit#--+' ------------------'-- 7 Y. . .Date__ ----��-- ---- - ---1 Septic Tank (Specify Requirements) --- -- -- -- `� — =` ------------ !' Disposal Field (Specify Requirements): i i• e. -------------- =-- - ----- ----�' ----- - i --------------- ----= ---i- - ----------------- - -€-- _ -------- ----- ----------------------- ----i, -- ------------ --.-------------- -------- -------------- --------- {Dr`aw exi f ng and required addition on reverse side) . I hereby certify that'l c hove prepared this.application and that the work will be done in- accordance with San Joaquin County Ordinances, State Laws; and Rules and Regfulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify that in the performance of;the .work for which this permit is"issued, I shall not employ any person in such manner as to beco esu [e toor man' _.Compensation laws of California." i .f Signed ---- = t l Owner ; BY------------- -- ---- - - ----- -- -..__Title y k (If other than.o ner[ - FOR DEPARTMENT USE ONLY I y n - } APPLICATION ACCEPTED B . 1- ---- -G� -- :-- - DATE !rte' DIVISION OF LAND NUMBER---------- ---- --------- ---�---------------------- =-- DATE---- --- ----------------------- --------------- ADDITIONAL COMMENTS-------------------------- i ---------------------------------------- --------------------------------- ---- ------- ----------------- --------- --------------------- ------------------- ---------=------- --- -------------------- -- - ------ - # -------- Final Inspection �b)F_�_- ---- -. - -------------------------------------------------------- -- .------ = D`ate ------------ .-.-- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7176 3M