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FOR OFFICE USE: FOR OFFICE USE: tL APPLICATION FOR SANITATION PERMIT ---------------------------------- ' (Complete in Triplicate) Permit No--- ------___ - ------------------------------------------------------- Date lssuedN_-_o?_j-`?9 --------------------------------------------------------- This Permit Expires 1 Year From Date Issued i 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 115 ----- �C ----- i._..CENSUS TRACT Owner's Name_.______,,. �___ i E Address.- ---- - - --- ems - 1�/-- -- - --- --------- ..__-_.._..'Cit -- e- Zi L---- Contractor's Name ? License # 32- f�_.Phone Installation will' serve: '7 Residence ❑,, Apartment House.❑ Commercial ❑ Trailer Court- Motel ourtMotel ❑ - -Other--- ---- .:.,7- ---------- Number ---- -Number of living units: ----------------Number.of.bedrooms,. ....Garbage Grinder.__..._._ `-----•----- ------- Water -----Water Supply: Public System and name = --=-- -- ------------- ---- -----= __ ---.-----__ - - -- ------ Private Character of soil to a depth of 3 feet: i Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑- 'Clay Loam c Hardpan E] Adobe [ Fill Material-- --: If yes,type ,t--------- -------- ' 1 ---_.- ---_-.aa I (Plat plan, showing size of lot, loeation of system in relation to-wells, buildings, etc.'must be placed on reverse side.) NEW INSTALLATION- ]No septic tank or see age pit permitted if'public sewer is available within 200 feet,] PACKAGE-TREATMENT"'['"] SEPTIC TANK [{] Siae �__ __.t __________--------------______Liquid Depth._. _ _______:__-. - r ;Caacit �, P:_----'TTYpe- __._Material_-- _No. Com artments__---- ---------- ---' P Y �= P _ - .. .. Z :Foundation-,'-..- 4 Prop. Line_�� -----Distance'.to nearest: Well__.___ .___-_._.. ..._ LEACHING LINE' ] ] No.Bof Lines-:--Type Filter Material'Length of each line._._ __ :.-.._.Total Length-:,_:_ `Q _______________ Yp -----✓----Depth Filter Material.------ / ---------- ----- ---- ----------- ------- ] Distance;to nearest: Well.!---- __-----Foundation_--'___7/4e ___.. Property-Line-- ---�� #.____ ___ [ Depth__I `p _. 1 ' Q.Number----------------------_-__------ Rock Filled Yes NolEJ�P '�•�; Water Table Depth.__'-----_-__--rte- _ _: _ Rock Size --------------- 2 r 4 '. .__y__________________ i Distance to nearest: Wel _ Foundation__-__ .. .._._ Prop•'Line.-.-_-- + - < I REPAIR/ADDITION (Prev:Saritatia'n2Permit# - Date------------------------------------------ - 4 Septic Tank (Specify,Requirements)--`' -------- ___-----------=--------------------- --- - ---=--------------: ------------------ ----- - DisposalField (Specify Requirements) _---------------- ------=--------------------------------- ---------------------- ----------------------------------------------------- ----------- --------------------- ______________________ _______________________________________.._ _ ______________ __ -____ _ _. !------- i _ - - - ------------ r ' ]Draw existing and required addition on reverse side) I hereby-ce t-ify.that l have prepared.this application and that the work will be done in accordance with#San Joaquin County Ordinances, State Laws, and Rules4and Regulations of the San Joaquin Local Health -District. Home owner or licensed agents signature certifies tl e64oilowing 3 "I certify that in the performance f the work for which this permit is issued, I'shiili not employ any person`In such manriier as to become subject to .Workman's .Co nsation: laws -of California." Signed----------- _ -Owner . �_. ..r_.. .---:-- -- C BY :---- 4k Title -- --- - ----- a �r (If other fh6nfowner) ; • ' R DEPARTMENT USE ONLY y , APPLICATION ACCEPTED BY-;---------- ---- -- DATE. = ' `` ---- -------- DIVISION OF LAND NUMBER..--- ' ------------_-------------:-------- -------- ---- --- --- - -- DATE.--------- k - - i ADDITIONAL COMMENTS------------------ -------------------------- ----------------- a � " -� - .-� F r __________________________________.__.._------.-:- — " . � - I -. -:_Final Inspection _ — w Date - - FH 13 24I _ 525677 REV. 7/76 3M SAN JOAQU N LOCAL HEALTH DISTRICT F& w 'joll•-