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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- --------------------------------- �$'— ? � ., (Complete in Triplicate) Permit No.- _..___ . Date --------------------------------------------------------- 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/LOCATION ;:; :._ 0. H.�F D ' -- CENSUS TRACT ----- ------- ------- _i \I41 Phone Owners Name = = --7—a,- - -- � -4� ._ Address O �� I : _city... -ziP ------ - ----- ----------- - -- -- ; �e e_ - License___.___.___ 3-=---Phone, V164---"��67---- Contractor's NamInstallation will serve: Residences; Apartment House.0 Commercial ❑ .Trailer Court ❑ if i.. .. ._.. Motel F. Other ------------------------------------ ----- ' Nu,mbe�of living units I_?__ Number of bedrooms-._�.___Garbage Grinder ._ � Lot Size "` � -,_ _ „ � - _ , Water Supply: PublicSys=emand'name---------------- --- -------------- :-----` -- .� T - - -- Pl ate Character of soil to a depth of 3 feet: ` Sand ❑ Silt❑,, Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam E] ..... 'Hard�an Adobe Fill Material.............If yes,type---_-----------._____.--------- (Plot _____ _(Plot plan, showing size of lot, location of system in relation�o wells, buildings, etg. rhust be placed on reverse side) NEW INSTALLATION:'' -`(No septic tank or seepage pi `,per` tied if put-fic'se er is-available within 2'00 fee)' Se-------.1x -------- -. -- --____--Liqus > PACKAGE TREATMENT -SEPTIC TANKh "IQ i Capacitylx�U -_------J a_- x\ Material-__ ----No., Compartments_______--_- -- i I ' 4 .... :Distance to nearest:.Well _ - 1 - -_---------Foundation . ...- (4___f'____.Prop. Line--5-- - +- Z. `". ,�'S.- -----------:Total Len` th. X74; LEACHING LINE' No. of Lines:-::::: -_- Le�ngt} tof each lineg ' ,'D' Box-----�Type Filter Material _ ___.Depth Filter Material--'--/?_ ____._____ ___________._ _ ! -f— Distance,to nearest. _W. ..elL { _3{__Foundation------- . . Line__:____ __________ _. Y SEEPAGE PIT Depth.Z>-i- .--D.iame'ter. -j3m4— Nuilnber ___.._. 7, :Rock Filled Yes No ❑ { _ 'Water Table:Depth s---------- ----- Rock Size--� - -`----- ------- -. .- Dist"ance to nearest: Well-------f- ---- --------------------1 oundafion--±------I!v------------Prop. L-ine__.�-------------------- REPAIR/ADDITION (Prey. Sanitation Permit#- : ---. .Date-----'- -----) Septic Tank (Specify Requirements} ------------------- --_------- -------------- ------ x_ - Disposal Field (Specify Requirements)---=--- --- --- -------------=-------------=------------ -----------------------------•---- ----------------- ---- ------ ---- ----- --- ------------------------------------- --------------------------- ---- ----- -------------------- ------------- ---- - --- (Draw ezisfing and required ad'dition,on 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: ; I - "I certify that in the performance of the work for which-this permit is issued, I shall not employ"any person in such manner as to become subject to -Workman's Compensation laws.of California." Signed-,--.--.--.---.-.-.-.-.-------s blrc 1j1$-E-� 7_C f -Owner Tte BY- - -'.---- than.owner)(If other ------------------------- { S • � � -FOR DEPARTMENT USE ONLY -' ' � *'-V. �- APPLICATION ACCEPTED:-BY______ _-------- 1 1 f C _ - -- DATE. DIVISION OF LAND NUMBER.. _--- ---- --- ----------.DATE--------=---------- ------------- ADDITIONALCOMMENTS------------'--------------------------'----- ------------- ----------------------------------------------- ------------------- --------.-- ------------------------- - ----- ----'---- -- - ------------------------------------------------- - ------------------------------------------' --------- ---- -------------------------------------------- --- -------------------- -------------------------- - ----------------------- - ------- ---------- ----------------------- = -----------------------------_-- --------------------------------------------------------------------- ---- .a_ ------------------------- Final Inspection b �_- -- _ . ._ . ^., L__Date_= -- --- EH 13 24 SAN JOAQUIN LOCAL HEALTH'DISTRICT F&5 21677 REV. 7/76 3Mf