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FOR OFFICE USE: _ FOR OFFICE USE: ----------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No.. .-___-_ Q (Complete in Triplicate) _ ------------ .,:.--- --- --=-- ------ w *.F (. Date Issued.5�.1__ -7.7 < . ----------------------- This Permit Expires 'I 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regu ation 4 #JOB ADDRESS/LOCA --- - = ------------------- ___ ._ --------.__.CCT �U�STR Owner's Name` ` ------ --- =----- --- Phone------,--- -- '-- [ .:___.. Address - ---- ---------- -----= City --.-- r�ipz x//17_ � 3 Contractor's Name---'----------- �------ ------- ---- ------- - ---------- License'#` ;RL4<r Phone. Motel p Other u.. L] - . L....i..__ .er* � [ r In will serve: �! Residence A artmen# House Commercial :Trailer Court i Number of living units:--:__- .:__-?__Nurriber of be -.Garbage Grinder------------ L ___--_.__.___ ________ Water Supply: Public System and:name---- - ----- - - ------ -----------------------------=------------------------=--------------------------------------------------------Private;9l Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat 0 Sandy Loam b��.Clay Loam ❑ Hardpan EJAdobe.❑ Fill Material-------------If-yes, type-------------------------------- (Pl8t plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse,side.) NEW INSTALLATION: [Nolseptictank 'or seep ge pit permitted if public sewer is available within 200 feet,) I PACKAGE TREATMENT `SEPTIC TANK "1'.5ize:_ [ [ i i ` C '' X .�_----- .--Liquid Depth_ C/. - ---- x - ; Capacity_: �_ -Type_ Materr p ___ _ # _-______No. Compartments f -! l' i ' ! LEADistance to nearest: Well.:...... -__.- ,E ot6in`dation. �.- ------------Prop. Line--------------------------- LEACHING LINE: [ No. of:Lines 3 : Length of each line i� L� - _-_-Jotal .Length. �:- __ D�Baxf-_ �_._.f_.Type Filter Material_ -�_ -_.DeptLi Filter Material _� ._.- ---- --- Foundation _ 1 0 = .__- -•.Property Line-----`!--------=------------- SEEPAGE PIT " Depth ---- Distance nearest: .. .;. . Yes -_ a , a, [ l p. i Number _-- _---- k Filled Yes.O Roc No Water Table Depth-------------------- � Rock 5;ze- - : ounation__:_-. _ ______ __']istanceto'necirest:"Well:_._ Prop. Line---------------------------- REPAIR/ADDITION _ . _.__-_-_.._, _REPAIR/ADDITION (Prev. Sanitation Permit# - ----------------- - -Date Septic Tank (specify Requirements) ---------------I-------------------------- ----- - --- - ------ ----------- - ---Disposal Field (Specify.Reg ementsl---------------------- ---------------------------------=------ ------------------ --------------=------------- ------ ------------------ -- ----F I J + --------------------------------=------------------------------------------ ------------------------------ -------------- ----- ------------------------------------- --------- (Draw --- ---[Draw existing and required addition on'reverse side) i 1 hereby certify that-I have prepared this application and that the work will-be done in- accordance-with San Joaquin County Ordinances,-State Laws, and sRules and Regulations of.the: San Joaquin Local Health District, Home owner or licensed agents signature certifies the following': i I . "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 Signed---------- ----------------------- p - -- --- - - ----liforn to become subject to.Workman's. Compensation,lavis of Ca ia.". . Owner By -------------------------- ��' ----- -- -- Title'_ : -- -- (If other than owner) _ t FPR PEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --- - --`----- ------------------DATE--------- ---- DIVISION OF LAND NUMBER... ----- --- ------DATE------------------- -- ------------------- -------- ------ - ADDITIONALCOMMENTS--------------- --------- --------------- ---=----------------------------- ---- -------------------------------- -----=------------------------------- ---- . --- - -------------------=--------------------------- -------- --------------------- ---------- -Inspection by:------------ =y - _..� .,.�� _ ri ,� Date' = , .. EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT a&s 21677 Rev. 7/76 3M