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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ------------ (Complete in Triplicate) Permit No..7y-_- f ----- -- This Permit Expires 1 Year From Date Issued Date Issuedv!F-=fS 79 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: . a v JOB_ ADDRESS/LO ION r_ �_.l_ _C_----./]l_- ,a { CENSUS TRACT._:..--------Owner's Name-._"-._ /' � �_ Phone Address--- ---- _ _ i - - tY ------------zip r Contractor's Name------ � - ------- - —=-License-#�. � -- -_Phone_ F,Installation will will serve: Residence [D Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ O her----------- :. Number of livin units:.__-"___-:__"---NumE;er.of bedrooms_____:_____Garba e Grinder 4 # g ! g :rinder- ----- Lott Size._-._ i ------ _ --- -- `------- Water Supply. Public System and name ____________ __ _ _ - ------------ - Character of soil to a depth of 3 feet Sand Silt Cla Pri e f ❑ ❑ y❑ Peat❑ Sandy Loam 0 Clay Loam ❑ at Hardpan [r,-�.AcJobe7b�i- Fill � ---V�f I y Material: 'Y ._. � a �. yes, type---------------- t F (Plot plan, showing size of lot, location-of system in relation to wells, buildings, etc. must be placed on reverse side.[ NEW INSTALLATION: :(No:septic-tTj or-se 'age pit permute ublic sewer is available within 200 feet,} PACKAGE TREATMENT [ ] ''SEPTIC TANK�[�] Size" _._ ` 4 ` A/ cf� 1' f ------------ ------Liquid Depth_.--------- Ca acit_ Q'� Type _ ( ; � P Y---� - ��_Materia __..�.,,��_-""-__No, Compartments._-__-. _"" ' Len sof each lin Foundation------- -- =�1"' ...Prop. tine-------' -------- - --- -=+ } Distance to nearest: Well_.._._.:__.._:- - LEACHING LINE; [ ] W.No...of Lines.=------- g e,. D' Box-,--.-/,- ,�jT"' a Filter Material._ '�Z__ D � � Total Length._,=_� _ _ _____ _ t a �' YP `S 1?--'-----Depth ept Filter Material---- - - _; •t �_ h ate ial ��--, - / /C -< i -— ------- Property Line-- ' } 3 - is#}race to nearest; Well -:-.. -".Foundation.__ _ -"fib SEEPAGE Plfi f �___ Diarrieter---:� y - um er__- - --- -- ` Rock Filled Yes o ❑ Water Table Depth = =� = ------------- -----Rock Size.• �� 11 ----------------------------- Distance to nearest: WeIL-----_____ :-�_-: _-_ E T / - ----._Foundation---- --t-V-------------Prop. Line ' - r REPAIR/ADDITION (Prev. Sanitation Permi##__ ... Date = } �: - Septic Tank (Specify Requirements)-------- -------------------- ------- - ------=-------------=- ----------------------------------------------------- � ---- ---=- bis posal Field (Specify Requirements)----------- ---:____. i - ' --------------------------- ---- ------------------- ---------------------------------------------------- ------------------ - n (Drew existing and required addition on reverse side] �`" - - -" T 1 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 District. Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work fog which this permit is issued, ;I shall not'em to an "_ . to become subject to Workman's Compensation;laws of.California." p Y Y person in such manner as . Signed- - r, - -- -------- Owner BY------------------ ?, . _____Title6 I '(If other ficin owner( a FOR DEPARTMENT USE ONLY ' 4 APPLICATION ACCEPTED DIVISION OF LAND NUMBER ______ _ ----------- --DATE.--- - f --- ----------------- ------------------------------ -----------------------DATE I ADDITIONAL COMMENTS-- ---------- � ��- ------'--------- ---- -- .. .-- -- ------------------- I -- -- - --- ----------------•------------ -------- -- :-- - ------ ---------=------=------�------=------------------------------------- -------------------------------------------------------------- ----- --------- - Date. Final-Inspection by._--_-""------ �-- - - - ._ .. . ----- ----------- --- EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT FB,S 21677 REV, 7/76 3M