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FOR OFFICE USE: FOR OFFICE USE. ,� APPLICATION FOR SANITATION PERMIT ------------------------------2` Q---- Y' (Complete in Triplicate) Permit• ------------------------------------------ ------------- --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued-h_- 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: tr JOB ADDRESS/LOCATION_ ------------ ------------ --- ------/;---- ---S , ---- -- CENSUS TRACT_- -------- ----- -----------° Owner's Name.:— -- -- -- - -- --- Phone-- � g. �..: .. h Address------------ -----. ?� r- M . 3 W- --� ...... ---- City- --- --- Zip __ e ... ------------------------------- C ntractor's Name-_-----p --- -------- �' ------License #_. 7 Phone,_T�Lt_lo 1?4Q7-. ' -------- Installation will:swr e; Residence Apartment House,[] Commercial ❑ Trailer Court ❑ - .. Number of living units:__, _ Number of bedr-ooMotel ❑ms Other_G' b 'e Grinder_----------Lot Size______ Water Supply: Public System and`name----------- :/-------- ------- ... ` `---.---- -- -----------Private -------------- -- Private ❑ depth of 3 feet: Sand [] ,Silt ❑ LClay ❑ " Peat ❑ Sandy Loam ❑ Clay Loam ❑ i Character of so aw Hardpan ❑ : A�be Fill MaterigI.............If yes, type________________________________ (Plot plan, srhowing size of Pot, locatio,�n/of system in relation toiwells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION:" {No septic�ank or seepage .pit permitted-if..publ.ic-sewer-is-avoidable-within 200-feet,)---.,------'--- PACKAGE TREATMENT"[- ]-.-;-SEPTIC TANK""[] ;.. Size---- --- ----- ------------------------------ ------ Liquid Depth-- ---------- p y '.�-' 'Typ --Material__ ------ No. Compartments------ ] f (,J + ' f �Ca ,acct w ------' e- ------- ---- - --------- � - --- 6, :Distance7to.nearest::,l�/ell :___.-__------=-- --- --- --.-Foundation--___--- ----_:,_- "._Prop. Line--------------- _---- ; �+ - . .� i ` LEACHING LINE: [']/.No. of Lines .____`Length-of each line _ --------Total Length _.�---_ *_- D Box �ye�F ter M eriaf` Depth Filter Mr�fen _ ___ ] _ Distance to nearest: Well--.r- -------- 1 Foundation--._ _.___._._____.-------PropertLine +__ .____ SEEPAGE PIT �[ ] Depth_ _ Diameter -_ �_Numk�er_. __ __ -------------- Rock Fill' es ❑ � No ❑ Water Table�Depth.__;______ r_ Rock -Size._________ ! • -- -- ___ 1 s Distance to near-est: Well •. ______ ____,_�_______ --_ .Foundation._. .-__ '_____ _.P,rop. Line--------:------ ------------ REPAIR/ADDITIdN�(Prev: Sanitation-Permit*- - ___. _ ---------------Daitg ___- ------------ Septic ._: .___Septic Tank (Specify,Requirements[. = - ------ ----- - - ------ `' V, ----- "i •--------- (,' - 1Dis'posal Field{Specify.Requirements[:.'.` -------------------------- ----- -----'------- I----- ---- - - .� u ----------- --------- `� {Draw ezi; ing and required addition on revue`s e - , I hereby certify that.l hay4k prepared this applic�n-�aynd •'that.the work will be done in accordance with Sari Joaquin County Ordinances,, State Laws, and Rules!and Regulatioh- of the 5an Joaquin Local Health District, H6in;_owner or licensed agents signature certifies the following: ' "i certify that-in the performance of the work for whiich this • ermit is issued;1`s`hall not employ cinyperson_-in such rcinner as to become subject .to Workman`s. Compensation laws of California." r Signed-------- ----- -Owner i a t F---- - r "Z` h r BY ------ = :---- ----- Title---- ------ ------------- - = E (If other than owner) ( FOR DEPARTMENT USE ONLY` i + APPLICATION ACCEPTED:-BY- C ----- -------------'----------- "-- ------- --•---._DATE.- ------------- DIVISION OF LAND NUMBER:_ = ------ ----------- ----.-------. --DATE--------------- ---- ---------------------•-'-_- t A ADDITIONAL COMMENTS..-__ --n -._- - ' - ---------------------- ---------------- ---- ----- --------- -------------------------------------------- ------------------------------------------------ _ ---=--------- -------------------------- - ----------- -------------------- - ------------ _ --`-•--------------------------------- -- ---•--'-------- ------ --- - -------- �_ _ . - _ - ------ -- -- - -------------------- Final•Inspection by:- --EH 1'3 24 SAN JOAQUIN LOCAL HEALTH DISTRICT r&s 21677 REV. 7/76 3M