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FOR OFFICE USE: FOR OFFICE USE: -APPLICATION FOR SANITATION PERMIT p a- Permit No.. c�--,11 -: f . {Complete in Triplicate) ------ ------------ •--- ............... ----- Date Issued_.1 -1�_.7.b ------------ ----- 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.,I .� i^.ol� �, ..... -----------CENSUS TRACT....:__ __ ✓ C'... .�.T. ..- = .......... -- •---- Phone.0.0— 7 .�.. .. • . Owner's Name.._. .....,. ... ... ... ........... ••--: .. _ ! S� - --- Address--- ��/��. fJl�.. City...,�itn. �n P g- Contractor's Name.-.....C�.G..c� 'l�Y... .................................--- "--- -...... License #.......................... .Phone-------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other— - --- ------ Number of living units;--------------- Number of bedrooms...3-....Garbage �- �,.4 Private Water Supply: Public System and name---= t j- _ 'r--,S _.E.7 ,-.. -...--- . •.... ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt I] ,Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam Hardpan E] Adobe ❑ Fill.Material.. .--- .._.If yes, type..----'--"------------- -_:-- -- ]Plot plan, showing size of lot, location iof system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION. (No "septic tank or seepage pit permitted if public sewer is available within 200 feet,) _ PACKAGE TREATMENT ( ] SEPTIC TANK [ ] .-Size..--. ---- Liquid Depth.-- Capacity-.-. ' �-�-- T e------------ ---.. --Material--------------.-----------No. Compartments------ •------ --------------- . -- -�--.-- YP Distance to nearest: Well--------------------- ------ ------Foundation-------.-- . ...__... Prop. Line----.--- --- LEACHING LINE [ ] No, of Lines-----------------------------Length of each line.------- ---. Total Length ...._..-„.----...-- i ' .. -� rest: Well_-=...-.: Filter Material............------- ------- Distance -- -- ----�----- ..... ..__...- j 'D' Box----- . Type Filter Material-.-....-"----- .--,,Depth i --------------------------- Property Line............. ...... -- ----- k Distance•to neo - �- SEEPAGE PIT [ ] p -Depth.-.-.. ------...Number--- ---- ----------- - f - • --------------Rock Size-..------ ------..._.. -----------••------- ---- Water Table Depth----------••-�------� �--•-�-� �------ - Distance to nearest: Well..................... --"-- ........ ------.Foundation................... ......Prop. Line---- . ------....--- - a REPAIR/ADDITION {Prey. Sanitation Permit#------.--- .. - -------------Date---------- ---- ----T.. ) I Septic Tank (Specify Requirements)------” .... --- . -.�-.>C-- lam• Q� Disposal Field.(Specify Requirements)-I.,/ - t J P, ----------- ------------- --------- ---- } .... - -------------------- ----- ---------------------- - � (Draw existing and required addition 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 I Ordinances, State taws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: t "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 becom ct Workma ensation laws of California. ` ------ --------- ------Owner Signed--.. ... . .._. Title.- , ... -------- -��---- - �- / (If other than,owner) FOR jiEPARTM T USE ONLY APPLICATION ACCEPTED ....--.... .. ...DATE ...... I a- ------ DATE s DIVISION OF LAND NUMBER--, -- --- --- --- .... .. AQDITIONAL COMMENTS...-.. `"-- t ` ------------ •-........ ..---••.................. -----------_-------••----------------- •... .•----•--- -•----- = Z..-..`.. --- - Final lnspectian b -------- Date- "E .. ......--........ Y' F&S 21677 REV. 7/75 3M CH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT