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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT G3 ------------------ -----------------------% Permit No. TM , (Complete in Triplicate) f ------- ------ t `k 7� 4 Date Issued_Z .._ / _ ------------ --------------------------------------- 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 herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION._... .��. -- . '---- ------------------------------ --------- ;_..:CENSUS TRACT.-----=-- ,;._._._;_:.• Owner's Name_: -- ` Phone ..---- _:__ : . Address - C� zi f Contractor's Name ---- ._ ` " ..-License # �� /J 37 Phone-W 5_. ._._� ----- - -- - Installation;will serve: Residence Pq-'-_Apartmen-t House.❑ Commercial ❑ `Trailer Court; ❑ [ - Mot'l ❑� !Other I i + Number of living units----- ---------- `+ g _ /, ------ � !_.., Number'of bed room s_�_.________Garb a Grinder__._ ___` Lot;Size:___-- T i E Water Supply: Public System and name--------------------= =::_ --- - ------- --- ---- ------------` - --------- ---------------------Private X Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 'Gay E] Peat 7] Sandy Loam E] Clay Loam_ El Hardpan E] Adobe Fill Mafieria.l__ _ . . ...If yes, type ------- - ------ t , 1 (Plot plan, showing size of lot, location of system in relation to;wells, buildings,.etc.must be placed on reverse side.) NEW INSTALLATION:— -r(No,septic tank ;or seepage pit permitted if public sewer is ovpilable within 200 feet,} } PACKAGE TREATMENT Y SEPTIC TANK ' --------------- ------Liquid Depth.!----------------.---- ---� [ } : [:l� F Size -t --' i opacity-- 'Type_-_ ---- =--------Materidl ------------No. Compartments-------=- ------I------------ ., .. w.. ..Distance'to nearest: We11-.,- _: -----Foundation----- ------==----------:_Prop. Line----------------------- LEACHING ---- --LEACHING CINE [ ] No. of Lines--------------_=-- ;_---.Length of each line-_-, '__- :;,-.-Total.l.engthl.__.--- - --- .'D' Box---------:__Type Filter Material :-Deptht Filter ` -- n' ,.✓ _• es: --- Material.-_�_.___.__r_ sce to nee I ---------------------FoundFtion- ------------`----------.Property Line-.-------.-fE-..-.-.-_-.-.-_--_-_-.. -_--------.---_-_- SEEPAGE PIT Depth nearest: ----- = � _ --- ----Number------- --: -'---____-- R k Filled s E) No Water Table Depth---=------=-------- ---------- ----------- .Rock Size-------------------------------------------------- Distance.to nearest: Well-------- ...--=---=-------- ------ /Foundation.-- ------ - --- -.Prop Line--------------------------- REPAIR/ADDITION --- ------------------- -REPAIR/ADDITION (Prev., Sanitation Permit#----------'-.~7 ' *---- 'Date------ ------ ---- -----------------L. .a Septic Tank (Specify Requirements)-- ----- - t --- _ ------------ ------- -Disposal Field (Specify Requirements) lp2 V -----f------------------- z ------`-------------=------`-------------=----- --------- -"A (Draw existing and required addition on reverse side) I hereby certify that.l have prepared this application-and that the work-will be done in accordance with San Joaquin County ' Ordinances, State Laws, and Rules and Regula.tio_ ns of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: : Ii "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 b[ea to rkman's .Compensation laws of California.'."- . . . I Signed----- - - Owner -_ __-. --_____i___ ____________________________ _ BY _ r- a Title ------------------------------------------------------------ Z - - l (If other than ner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------ -----------------------------------------------DATE./l. ` - ---------- - ----- DIVISION OF LAND NUMBER-------- ---------------------------------- DATE---- f ADDITIONAL COMMENTS ------------------------------------ -------------- { -------------------------------------------------------------------------------- -----------------------=--'-- ----------- ----------------------------------------------- ----------- ------------------------ s --------------------------------- ------------ --•------=--------------------------------------------•------------------------------------------------- --------------- ---------- ---------------------- �------------------------ Final Inspection by: - �-d- n,------------------------------ - Dafie_ - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M