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FFOR OFFICE USE: OR OFFICE USE: APPLICATION FOR SANITATION PERMIT -3/V (Complete in Triplicate) Permit No.__��:-------------- ----------- ' ------------ ,,// i1 Date Issued.--?`__-� � �� i --------- __-------------------_------- This Permit Expires 1 Year From Date Issued ,i i 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 wit _County Ordinance No. 549 and existing Ryless: JOB AIJDRESS/LOC TION.- --------------------------------------------------- ION :. -__------------------------ ----------- ------8----- --- RACT------------------------- Name G `_ ti.__ ------ hone , .. --------- Owner's Address----- -/ � .'I = --- ----- ------------ -- ------ ---- - -----=-------Cit - --:.: -- ------- ---Zip --- --i ------ + i I -; r �I _ 77 / /!�' Contractor's Name ,...- -- -- - -- ---------- --License #-d (._.!.- S___ Phone- -`-----a7------ Installation will�se�r�e: I Residence`-.,Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑Other- `-__'_.._ - Motel Number of living units:__.__. _.I�._Num'ber of.bedrooms_--��_-__'''r_Ga bilge Grindex___:_.._____Lot.Size a1 ---:------ W ter __._Water Supply: Public System and`name------------------------- -=-- -------.' :_- -". __.Private �. I?P. - --- - ---- Character of soil to a depth of 3 feet: ` Sand ❑ Silt ❑ Clay ❑ ` Peat ❑�SdndyLoam ❑ Clay Loam ❑ .�) Hardpan`' Adobe ❑ Fill Material__ _________If yes, typed '`_',._.�.__..__.__. (Plot plan, showing size of lot,��location of system in relation to wells, buildings,.etc. must be placed on reverse side.) 'J�j NEW INSTALLATION:' (No:septic tank or seepage `pit permitte�d`i pudic sewer is available within 200 feet,} t[,f" l PACKAGE TREATMENT [-] ^'SEPTIC TANK ` Si e_ `__ ______ ____________-___"_ ________Liquid epth_:_.�'_-___________-__---- s +y , Capacityf4_.____.---Type _ ---Material ) -tf -No. Compartments----------- � ---------- ----- f iDistance;to nearest: Well:.,__....: ,�. /z. -___._,_____„_Foundation.____ Q_________ -Prop. Line.,_S.s-_ -_ ' g � � i LEACHING LINE No. of 11�Lines___._ __________________Len Length of each line._ ._Q___ �, _,_---.Total Length.____/,�,Q___________________ d a D' Bo ------------Type Filter Mat�rial_ -�ltC '--Depth Filter Mate al_------/L7.-C-------------------------------------------- .4 - i l Distance to nearest: Well-'- �a_ F;oundation___._ Q______________Property Line_____.!__ '____._____ SEEPAGE PIT DeptWatehl __. _-___.Diameter_. ✓ .. ____Number______ _______ __ ____ __ ��' Rock Filled ;Yes No Table De th _._ .. ---------_-- - _.Rock Size ; Distance to nearest: Well_'_X04_._-__________________ _______Foundation__,___.___. :__.Pro Line.____ __. P i REPAIR/ADDITION (Prev.,Sanitation Permit#-- __`_- __________ ______ ?______:_=:__.Date.='__ I ------ M Septic Tank (Specify Requirements)--------------------------------i------- ----------------- f. DisposalField (Specify Requirements)---------------------- ----- --------------------------------------------- ------- --------------------------------------------- -------------- I ; ------------==-------------- ----------- ---------- --------- ---------------- = -� = , ' d _ ____________________________________________________ (Draw existing and required addition on reverse side) I hereby certify that I have pr Ipared..this application and that they work will be done in accordance with San Joaquin County Ordinances,, State Laws, andliRules and Reg ula:tions' ofathel San.Joaquin Local_ Health District, Home owner or licensed a ents g signature certifies the following: i "I certify that in the i! x .T fy performance ofahe work for w ich this permitl is issued, .I shall not employ any person in such manner as to become b'ect to rk pn's C pens tion- laws of California.” ' v Signed---- ---Owner = �-�` - BY = - ---------------- -- =Title' t t i F (If other than owner FOR DEPARTMENTiUSE ONL•Yj APPLICATION ACCEPTED BY = t t�------"=---- ------ ---- DATE: �'��1--- ---------------------- -- r } 1 DIVISION OF LAND NUMBER- ---------- ___ DATE.______.___._.__.__ ___-_.------ ADDITIONAL COMMENTS--------M---------------- ------ -- ----------------- - - ---------------------- ------------------------I------------------ - = ]� t - = ------------------------------------ ----------------- -------------------- -- ------------------------------- -------------------------- -- ------------------ -------------------------------------- ------------- - ----------- , --- ---- - ^- r Fina! inspection by..,- C-: -� " r �rt- _ "------------------------------ _ _.Dafie J�=' --� 1%�� ter: _ _ � _ r r EH 13,24I1 . "216 7/76-3M SAN JOAQUIN LOCAL HEALTH DISTRICT --4