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mom.... � FOR OFFICE USt: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No..;7f==--��-- --�� -7) ----------- {Complete in Triplicate) J Date Issued..�'7=------- ---- 19 This Permit Expires 1 Year From Date issued oaquin Local Health District for a permit to construct and install the work herein described. Application is hereby made to the Son J This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: t JOB ADDRESS/LOCATION..3 - - J�1 -��•. CENSUS TRACT. -..-.Phone.-,. .. Owner's Name.. .. .. .. - � 1 City.. 4 �1; .Q.1�e�: �--Zip--p:_• - Address.. - .1..t.-;/. . .�1 _Phone._9- - �---...,.... Contractor's Name_-.�..4 k.. ... � �,. :..... License #.-"-• Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------- ---- ------------------------ 1 D 0 X �C------- Number of living units;---.I_.-,"•""--Number of bedrooms.-..Garbage Grinder----.-------Lot Size.._.: . ". -_-„_-,-_......Private ❑ Water Supply: Public System and name--=---- ----- -- Clay Loam El Clay Peat F-1SandyLoam ElY a Character of soil to a depth of 3 feet: Sand F71 ❑ Y ❑ Hardpan ❑ Adobev. Fill Material.. ...:. -...If yes, Type---------------------- --- - - {Plot plan, showing size of IoT, 'locatian of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT T ] SEPTIC TANK [ l -' Size......... ..... ....... '- ---------- -Liquid' Depth--------------- ----.-.-..:No. Compartments-------.:. - . CapatiTY- --- ------ -----Type-.---.... .- -.......MaTeriAl------- ---- - --- , Distance to nearest: Well------------------- - Foundation...... .. . .... ........Prop. Line.. '.1 Total Length ..: .............. LEACHING LINE [ j No. of Lines .------------------- -----Length.of each line.....-----..------- g 'D' Box..-....... Type Filter Materia{ -- ... -�---�` -..Depth Filter Material-- -- ��---- --�-� ----- ----••----- ..... --- -------------- 'D' . ..... ..... Distance,to nearest: Well------------------ -----.- Foundation--_------------------ Property Line...------------- SEEPAGE PIT [ l Depth -_-- -.. ..._Diameter--------------------Number_. .-----•-- .--- Rock Filled Yes E] No ❑ I Water Table Depth......-_--- •--•--- - -- ------- .Rock Size----- -------------- -- ----------------- I1 - Foundation .,--.prop. Line Distance to nearest: Wel .................. -..----- --- 1 REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------- --- --- ----------Date------------- -------------- Septic Tank (Specify Re Rueireumir �. � - -” �F•1 .�- '. ---'- .0 ............ Dis osal Field (Specify . q ementsJ � � _.., l --------- k.>ti1-1 - ---- ---- - l t ' [Draw existing and required addition on reverse side) ' application and that the work wiJoaquin County ll'be�done"in"accordance with San t I hereby certify that 1 have prepared this app Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents r signature certifies the following: I "I cert' that in the performed, I shall not employ any person in such manner as performance of the worts for which this permit is issu to beco subject to o kn n's ompensation laws of California." --- - ..-- �� -------- �---= ��-----�--Owner Signe - - •-- ... �----- ...,..Title---�- ---...---�------- By...... --- (If other than owner) FO DEPARTMANT.USE ONLY `. -. DATE ..... - APPLICATION ACCEPTED BY"-.---- - ------ - --„- .rDATE--.-.------- ----- ----- -- - ---- DIVISION - -DIVISION OF LAND NUMBER -------------- ---------- i�.ille......r,,e . E ADDITIONAL COMMENTS .. ._.._-. ------ C r^d. �. '� .._ . Dot QL �.. . ae.. Final Insgeesion �y:- --. .. -�-- FSS 21677 REV. 7 76 Final a 2e, SAN JOAQUIN LOCAL HEALTH DIS CT