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FOR OFFICE USE: i;;s 4 FOR OFFICE USE: ' APPLICATION FOR SANITATION PERMIT ----------------- ------ ----------------- ----------- t i (Complete Tiiplicatel` Permit No, -g�__ ------------------------------------------------------ -- F Date Issued_/D.-:-/,P 78' ---------------------__------_---_----_---------.-------- 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./LOCATI -._ l __ r . >r, f --------------CENSUS TRACT._ R Owner's Name. --- -- ----------------------------------- ------ -----------------.Phone --- --- -_-- ---------------------- Address. ---- ----- Ci G�------- ------Zi I Contractor's Name `_._._ ._ __ License #_ ®52.a/_-__Phone___3.6!F 39-3-A Installation will serve: Residence,�, Apartment House❑ Commercial ❑ iTrailer Courtr❑ ! Motel ❑ Other---=-------------------=------------ --- --- w Number of living.units:_._---.--__Number of bedrooms_ .__Garbage Grinder -`.___..__Lot Size_ r�� °________________--------------------------- Water Supply: Public System and name --- `__. : ----- :---- ---: I-------- --- ---------------------------------------------------------Priv, ate f Character of soil to a depth of 3 feet: Sand ❑ 'Silt❑ 'Clay ❑ Peat Sandy Loam Clay Loam 0 - ._ . ,...�HardparnE]---Adobe � y . ,"-_` y yp .- *---"`.� ` _-� _-. Fill-Material:""•-�If es' fi e�-�-- (Plot plan, showing size of lot, location,of sysfem in relation to wells, build €t ings c. must be placed on reverse side.) NEW INSTALLATION:` -`]No"`septic tank ,or� seepage pit permitted if public sew -s;vailable within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK �:}� �, Size X�._� IO / ; � f P Y YP. ��¢� t Liquid Depth _�___ _. t Ca acct ` I `"` 1 ® P nts Z.� :. � Distance n � W II-e . -_ _---`. ��`M"'�a,�ter�a�-•-�-�------- .No Compartments �, � o ea es . e /lL -- --_---- -=__,_Foundation--------------------------Prop. Line_.- -----•-------_.-•- a • ..- f LEACHING LINE [� No. of Lines---- __-._EN._ !..-Length of eei"6c"nes._ Total; Length.'._ ��^ -------_-_ /v��Type Material �"/----- D' -Bepth Filter Material--. v --�-- - -------------------------------------------- N. . r , Box .,.._..._...T a Filter Distances to nearest_Well i --- -- foundation------ .--------- ---Property Line--------------------------------t. SEEPAGE PIT (� DepthJDaamet r_f�75v :"'-,Number_r__--3______________ Rock Filled Yeses/No i. ..._x ._ - o _ Water Table:De th.5-d._!Jr---------------- -- --------- Rock Size'------------ - p � _ :�. _ Distanceao nearest:Well= :_��D___--___ _;_:__._._;Foundation: --------_.-:prop. Line._____�r_____________ REPAIR/ADDITION [PrewSanitation-Permit#C �. _ x..,f--------------Date- --- _- -_________------- IfiSeptic Tank [Specify Requirements}_.__ -- v__- _� :___-- _- - -------------------- -- ---- ------------------------------------------------ - Disposal Field (Specify Requirements)--- ----- --- ------- -------------------- -------------- ----- -------------------- ------------------------------ ------------------ --=------- - ------------=------=--------------- ---------------------------------- (Draw ------- -=--------------------- Draw existing and're uired addition on reverse Y Y ' prep p- �----- —�-1� .i .�e��.�s q � e side) • - T�' ,., .. r �:: .�:y:;�--�-�,. hereby certify that I have re ared this a libation--ana that the work will be done—in—accordance with San Joaquin County Ordinances,. State Laws; and Rules and Regulations - :the 'San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the'Work for which this fperrriit is issued, 1 shall not employ any person in such manner as to become subject-.to Wo*KCompens' at:oa lawsF Cclifornia." ` Signed-,-- r �} . _. -. --� ,Owner 1 BY-°----- - :` Title C/LC' -`f rC `- �- {I'f ner) - t I FORDEPARTMENTUSEONLY t- APPLICATION ACCEPTED B13 ---- - .-- -----=------=---DATE.-T-d _._.: DIVISION OF LAND NUM•B-ER ---t.- ------------------------------------------------ ---- :-------.: .:.--- ------- E --------- -- - -- ADDITIONAL COMMENTS�---Y L-~------------ ----------------------------------- DA7 -----==------------------------------------ -- - - -------- --- --------- ---------------- - --------- -------•-------------------=------- ` ------- ---1--------- •• - - --------------------- -------------------------------- ---------------- ------------ ------------------------- ------------ !� -- Final-inspection b �- ti----"�.. _ "---.----------------=- ----- ------- Date..�_U 1-z-�� e" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M