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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----"--------- -------- ��77 --- w SSS -� Permit No.lOpr- --------- --------- - r.[Complete in Triplicate) ------------ �, �� F � Date Issue .__. ? __ 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. 5A9 and existing Rules and Regulations: JOB ADDRESS/LOCA' N_..,;--... -- F ----------------------- ----==------ _ ----.CENSUS TRACT ` Owner's Name1?0 - Phone _ - --------------- I i City. _ ---------------Zip-------- Address-_3o3-- ----- R ------- Contractor's ------------------- --Lic - s . i Contractor's Name_____.--- - erase # f� Phon Installation,wi11 serve. Residence A artment House.❑ Commercial ❑ Trailer Court ❑ i a Motel t Other_ ------ g _ System and name--1--,- - --.---- ----- ;_. .. =---------' -----------------ze f Number of living units:__;_._ - Number of bedrooms___________.Garbage Grinder---. of ` Private ' Water Supply: Public Sy t --- ----- - ' Character of soil to a depth of 3 feet: Sand �] Silt Clay ❑ . Peat❑ Sandy Loam ❑ Clay Loam ❑ __ .. Hardpan Adobe ❑ Fill-Materia If yes, type -' (Plot plan, showing size of lot, location of system in relation towells,-buildings, etc. must be placed on reverse side.) ' NEW INSTALLATION: {No.septic tank :or seepage pit permitted if ublic sewer is available within 200 est, Liquid De th.__y---------- on -SEPTIC TANK [� Size---_ q P PACKAGE TREATMENT [ ]� . � I - N.o. Compartments � Capacity-1-043 _ T e �_L- -MateriaLL '-=- -- A P ._.Distdnce:to nearest: Well ----- +-------- -----= -------Foundation-- G!-� =-._--------Pro Line ! . ------- No. of Lines:---- a Filter Mateength of each line + ---:_--.Total Length __.__:___ LEACHING LINE [ ,...-. , : YP / l S�_/Pd4�,Depth Filter Material- = - D' Box____.'�_T .nal. � ..� Distance to nearest: Well_;-.i�_O.-- ---- . Foundation___. -- -Property Line__ -:- ----- ' # y .< .. .., w.,�.. k ed Y .. .. ; - -` SEEPAGE PIT [1�' Depth._0Z_-.:----Diameter----- 2-------- Water .-- --- Number__--o ---------------------- SEEPAGE ----- -------=------- Roc Fill es No RockSize---- ------------------------------- Distance ------- -- ---L------------ ' Water Table Depth---=-�-�--�-------------------- ------=---- ------Ro k S' d_�.�- -- Distance to nearest: Well-_, f_Q. - -----"----------.------.Foundation._.�_Q. ---- ---. Prop- ine__6- _-- ----- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------- --- Y '---.Date------=------------- ---=------------1 Septic Tank (Specify Requirements)----------- =- -------°--------=------ ---------------z--------------------- ----------------------- --------- --------------------- - s t -------------------------------------------- Disposal Field (Specify Requirements)------------ ----- - ----------"--"----_-- ' ---------------------- - - ----------- -- ---- =--------------- -------------------------------------------- ---------- ---- i --------------- (Draw existing and required additionon reverse side) 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 District. Home owner or licensed agents signature certifies the following: ' <y< "I certify that in the performance of•'the-work for which this permit is-issued, l shall,not employ any person in such manner as to become s.0111iject to Workman's Compensation laws of California." r t Signed- ---- : ......... Owner ----:------- it T le -- --- ow By-& - -------=----------------- = (1f other than owner) f. ° F R RT ENT US ON m -- APPLICATION ACCEPTED BY_ _ - -=-- --- -- - - 4 . DATE ._. -------------- ------DATE.------ t ----------------------- --------- -- OF LAND NUMBER_______ ______ -- ----- ' ADDITIONALCOMMENTS--------- -------------- ----------- ------.----------------- ------ ---------- -----= 7-------- -------- - --------------------------------- ------------=---------------- 'S . ----------- �-f -------- -- ----- ---- J --- ---------------- - � ---- ---=--------- --- -------------- --------- D -------------- M- _ - ---- --=---- --Final Inspection by.- DFas 21677 eev. 7I76 in SAN JOAQeH 13 24 UIN LOC HEALTH DISTRICT