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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ��y ---------------------------------------------------- 1 {Complete in Triplicate) Permit No--- _j _v- ---------- -.. .-.._____ - - _------- --- -- This Permit Expires 1 Year From Date Issued Date Issued-._x.3 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 CAunty Ordinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOCATION.f-/3' --------------------------- -`-----_ ------------~-F----------- ------- -�-----'---.CENSUS TRACT-------------------------- ----- Owner's Name �J-i = _.. 1 Phone7� ------------------- E Address 3oZ Ci ,--- ----- - Zi _ ' �' P----------- Contractors Name -----------------------------------. -- License #_ _ -� --Phone_y S_'_ f_ �__ -.__-_- Installation will serve: Residence ❑ Apartment House.❑ Commercial ❑ Trailer Court , .. ..' 4 Motel ❑ Other = ------- - oao Number of living.units:.- __7.- --_Number of bedrooms". __,___G rbage Grinder------------Lot Size______________________________ ".----,---_--_:____.__ V Cj Water Supply: Public System and name--- - -- w--__---_-- �_ ---------_--------------- -- .- Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ "Clay Loam ❑ € Hardpan-.0. _Aclobe_ _ _Fill Material �f yes, tYPe-=== :::----------------- (Plot plan, showing size of lot, location of system in relation to-wells;-buildings, etc, must be placed on reverse side.)' t NEW INSTALLATION:' `{Nod septic tank .or seepagep t permitted 'rf public sewer is available within 200 feet,) a t PACKAGE TREATMENT "'[ ] ISEPTIC-T----A---N---K-------[-�--Tye + ``Size- M"''"' - ---------�" - -- _ --""Liquid DeptFi y '- _."-". __ t �� Capacity:—., yp -No Compartments _ _ ... ..•S Distance tom nearest; Weli__�._____ - Foundation.___,_=,_>.___. Pro fine_______ �_ _______________ LEACHING LINE ( ] (rNo. of.Linesy� -_-__`________'__.__.Length of'each line...:..................{_,.,.,,,_.Total Length __,_.: -------------- ---------------- _ i l -r 'D' Box------------Type Filter Material-'------``. -----Depth Filter Material-- -- ----- --%------------ - ------ . . - =-Foundation. =--------`- --.'� _____..Property Line------------------- ---' Distance to nearest: Wel'I_____________________ p -----__- Rock Filled Yes❑ No ❑ SEEPAGE PIT [ ] , De fh---------- ---D.iameter._--_--------_-__--.Number------------ Water Table.Depth--- ---------------------------=--- ------------------Rock Size - a Distance�to nearest:-Well-""----:-i"- ----'-�":-:r.: _ __:._ _.Foundatlon:- :-----_---------------- Prop. L'ine-------- -------------- REI AIR/ADDITION --_- --------REPAIR/ADDITION (Preva Sanitation Permit#---------------:_--- ------_---:--__,------;_------Date----------------_--_---------------- ---*---"} Septic Tank (Specify Requirements)--.-_, ` • _.:;; - 1 _.. Disposal Field (Specify Requirements);._ . _`._ _ -- ----------- --:---__-__..----------- --- -----------•-------------------------------- {Draw existing and required addition I hereby certify that I -have prepared this'application and that the wor' will •reverse side] ' k will be done in accordance with San Joaquin County Ordinances,' State Laws; and Rules Viand Regulations of the San Joaqvin Local Health District. Home owner or licensed agents signature certifies the following: ) s '.1 certify that in the performance of'ahe:work for which this permit is issued, I•shall not employ any person in such manner as ) tog gbecomK .�ubcto Wo an s Cam ensation laws. of Califor ia." - ..Sined BY - -- — -----Title :- ------------ s t - (If other o than ) ner) EJOZ D T ARTMENT USE'ONLY : APPLICATION ACCEPTED BY---------- - - ----_- --------------DATE...-_.DATE...--/'- ' DIVISION OF LAND NUMBER ------ -------- --- -------- ---- ----------------------------------------------------- - ATE- --- --_ ADDITIONAL c COMMENTS-- = -- -------- ----- --------------------; --------------------------------------------------- --- =---------- ---------=------------- ---------------- - -- --`------ ------- --------------------------------------------------•----" ----'-- --------------------- _ -- ----- - Final-Inspection by::.. -------------------------------------- -----------------"-- -------.-- ------------- Date. ��a` ------ ------:---------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&S 21677 REV. 7/76 3M r