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V FOR OFFICE USE: FOR OFFICE USE: tz APPLICATION FOR SANITATION PERMIT- (Complete in Triplicate) Permit No, 1T_-_.14�1_O ------------------------ ------------------------- ---- Date •-------------------- ----------------------------------- 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: ' - e� C�&QP,0470N JOB ADDRESS/LOCATION--- ------ -: i------ -------------------- CENSUS TRACT ! Owner's Name :. , Phone �� 1 � i -_ _ ----- --- -- ----------------- -- x - - --------- - Address �1' .. = -`- -- -- -i .------- -- -city.... PQ. !! - ----Zi M J� .--�/V ¢. .... .-. �. _---------------- ----------- Contractor's Name---- .---------- i ---------..- /� - ---- ------�- -- ------- --- ----- License #----- -Phone__'.`?�3-"�%. lnstallation.will serve: _ Residence�j Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ -iOther. Number of living units------ -------_-Number of bedrooms,-aG rbageGrinder_----------Lot,Size------------�- ----------- � ---------.. -- - Public System name---- -_:, ---- __Water Supply: ------------ t p ci ._❑.. _ ❑ ' Y❑ ' Peat ❑ Sandy Loam' -Clay Lo - Private i Character of soil.to a depth of 3 feet: _Sand Silt Cla am ❑ Hardpan ❑•' Adobe ❑ Fil!Material---------_-If yes, type___ _-- .-----_------------- A (Plot plan, showing size of lot, location of:system in xiiation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No`septic tank or seepage .pit permitted if public sewer is available within 200 feet,) 04 r PACKAGE TREATMENT [ ]: SEPTIC'TANK ]✓ Size----------- ------------------ -------- - 1 u1di=D'epth. - ---- t i . Capacity. TYPe---------=--=-------- -Material----- --- --:----. -No. Compartments- --------- .� Distance to near: Well--------------- -----------------------------Foundation -------- -- Pro"' Line V� I LEACHING LINE [ ] No, of Lin ------------------------Length of each line._.,.---•----_--.---------------Total Length.--- I ------------_ /' - -- i D' Box--/-----Type-Filter Material--------------------Depth Filter Material----------------A_------ �- ----------------------.- -- s Distance to nearest: Well--------------- ------.-----Foundation--- ------- --------- Property Line----------------:----_---------:--- ..: . . _. . .... _.t.._..a... ...;.. SEEPAGE PIT [ ] Depth- r'=r r Diameter --.--:-- -.Number-- --------------------- '_ ! Rock Filled . Yes ❑ No ❑ , ydfer TableVepth.t - � 1 - .--.Roc ize �� - -- ------ - � i' Distance to�ar�"st Well.i------------------------s- ----------------Aoundation------ - -_- .- Pr pe n `" mit --------- - -------- �` Date--._ _ .:" - }_ .- _ --- -- I P I p NY Pr q an ] - .:---r----- _: � Se tic Tank 5 eaf Re ui, ents.--.. Dis saNField (Specify Requirements ---- - < �j)pe �-f" -�,��y�, i . '` _ = = . --------- � - � , - - ---------- ----- - -------�--�-.-- - - red addition on -=--- --- - --�----- ... ; � ! �[Dw existing�a�degtuir reverse side) e1 ' I 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 Rules and Regulations of the San�Joaquin Local Health DlstPict. Home owner or licensed agents i signature certifies the following: "1 certify that in the performance of'tli work'for which"this permit is issued, I shall not e.; ploy any person in such manner as to become_abject to Workman's Compensation elaws. .of. California." f Signed---- ' - Owner _ BY------- --- -- �---t- -- - .: ----. Title_ (I other than owner) G 3L u FOR. EPARTMFNT USE"ONLY APPLICATION ACCEPTED BY-------f/ _ - -------------- ------- ---------------------- DIVISION OF LAND NUMBER,------ ------------------------------------------ ----------------------- DATE ------------------------ ADDITIONAL COMMENTS-- -- ------------------------------- ----------=-------------:----. ----- ------------- -----•--- ---------------_------- ----------- I-------------- --------_- -------- --- = t ----------------------------------------- ------- - -- -------- ---------------- Final inspection by: r - --- -Date 'l -Y- ' EH '3 24 SAN J QUIN LOCAL HEALTH DISTRICT F&s 21677 REQ V 7/76 aM,