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.a^ 7Z ol�Qlk OFFICE USE; FOR OFFICE USE: l APPLICATION FOR SANITATION PERMIT [ - ----------------------------- ------ -- ? (Complete in Triplicate) Permit No._._7_______ Date Issued- /? � _. --------------------------------------------------------- This Permit Expires 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 h re bin described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.62-2- o- - G ` T- CENSUS TRACT--------------------------- ------------ - --- Owner's -- Name---------:G,_ � ��dN_�..------------ --.-.,-.------- '------------------- -------------Phone-_�°3�_—_217, 7 F Cont actor's Namey �l City --------------- ----- ----------------;----- i ` Zi SOTi!!1�° License #;-aJrY 3_Y33 - --Phone'-- -- --- --�-" `` � .- p.7. Installation w•ill._serve: R&sidencLK� wApartmen#.House.❑ Commercial_❑ •Trailer.Court-❑- - .� Motel-0 -=Other:}.-- `- _ Number of fivir,g units:_,. ----------Number.,of.bedr-ooms...'� Gar.bdge Gnnder___-_ -- Lot, - Water Supply: PjgMic System and name ---------------- --:: Private Character of soil,to a depth of 3 feet: Sand ❑ ?Silt Q Clay ❑ Peat❑ Sandy Loam ❑ 'Clay Loam i k Hardpan ❑ Adobe ' Fill'Material .t._....if yes, type-------------------------------- l (Plot plan, showing size of lot, location of system in relation towells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tarik:;or seepage pit permitted-if public sewer is a'v'ailable within 200 feet,) .. ... r. PACKAGE TREATMENT- [ ] SEPTIC TANK ` ize'.-_- —- ------- ------------------------ --Liquid Depth._ 4 c Capacityj�-W. A••-..__Type._ Mater'lal_. No. Compartments - - ----------------------- n -z- '`` .t 3 . _.. .: Distance to nearest: Well. ddb t------------ -- on - -------- :-.Prop. - ------ -- Founda#i _._ .�Q _.__ Pop LEACHING LINE'. No. of Cines-:---:-- ,- ---;- -- Lengthh of�eacrh line.------ ---------_ -Total. Length.__-----?+ ---- -------- D' Box.---lip _Type Filtef N1Qte�ial ---Depth Filter Material_- ---- -----_--------_..--`------------------------ --- - ------------------- --- M ... Distance:to nearest: Well_-_-ta . - + r � ` Foundat o - Line s, = f'• 1 n !d !T Property 7-�'t% R SEEPAGE PIT ] Depth Diameter. _. .�f_. Num`�ber _.~-T ------ y Y ti t ! - -----------I�Ock�Size -��}--------- p Rock Filled Yes No' • Water Table Dep#h--- ---------- - =- �-`�--- i -O --f------!t�-- - + Distance to nearest:'Well__: � -___- ___Foundation:_:.-_ _- ---__._ _'Pro Lfine_ _. ______________'___ REPAIR/ADDITION (Prev. Sanitation Permit#_a-_--_1------------------_---------------------Date------'-._-- Septic Tank (Specify Requirements)............ --------- ------------------------------------ ----- ------------------------ Dis osal Field (Specify Regyirements) { ------------ ------------------------------------' ------ I ---------------------------- - ---------------------- "' "`' JDraw existng and required 'addi#ion ori reverse side • i � - ;r� 3 ---------- ----------------------------------- I _ _ _ ------- - ---------- - I hereby certify that 1 have prepared this application-and-that the-iwork-will-beTclone-in iecordance-Fwith 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: : Y "I certify that in the performance of`.the.work for' which this permit is. issued, 1 shall'not employ any person_ in such manner as to become,--subject to. Workman's Compensation laws. of. California.". . Signed- --------------- --I : Owner - - ----- --------- BY-i { ---------- Title If rthan-owner FOR DEPARTMENT USE ONLY,; � � � ----'--- ----- -----° FF Z APPLICATION ACCEPTED BY__. ---------------- --- ----- I------ ------ -----DATE ------ - 7 ^ DIVISION OF LAND NUB -- - - =------------------------------------- --- - - ADDITIONAL COMMENl7S_ER----- =---. ----- - � - -- DATE ------------------- ----- -- --------- -------------=- --- --------------------- ---------- ------------------------ -- ' ------------=------`------ -- ----=-------- --------------------------------------- -- - --- -- ----- _--------------------------------- -------------------- --------------------------- Final Inspection.by:-- - = "------ ` " _„�” --� = - D ,. ----------- ----Date--_f-- � ------ �--- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21.677 REV. 7/76 3M