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i r� FOR OFFICE USE: ��%OR L rll t 11St: APPLICATION FOR SANITATION PERMIT t --- �- Permit No..----.-r34 ' 'p (Complete in Triplicate) . .............""-_..... -_. - ....._._. This Permit Expires } Year From Date Issued 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 AQDRESS/LOCATION........ --- -U ......_J"./.-Q�:�.T74//--.CENSUS TRACT................................ �i Owner's Name....`!�. l'(_ .... �j �� yy r Phone -:.U. d Z ... ;�. Address.. +� ../. - ../ CitY � Zip .. .f3 7f--..---- Contractor,'s Name v.kJA. ' ' License # Phone---- -----------------" Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other .... --------- .............. P Number of living units:......--------Number of bedrooms.-3.._..Garbage Grinder..t d...Lot Size.-.. ©X�.... .........._.. Water Supply: Public System and name_-.............. - ---• - .........-- ---•------------------------- ........------. -----------------Private ❑ Character of soil to a depth of 3 feet. Sand ❑ Silt ❑ Clay ❑ Peat 0 Sandy Loam [] Clay loam ❑ Hardpan ❑ Adobe ❑ Fill Material _ ___ If yes, type------------------------ Mot plan, showing size of lot, location of 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,] i PACKAGE TREATMENT ( } SEPTIC TANK Size--- --- -------------------------------------- - --- ------ Liquid Depth.-•-------- --- ....... � ' Material`..-.-...---------_-- Capacity-�--... .-- --------TYPe--------- - - ....No. Compartments---------------------------- -- ---• , ;1 Distance to nearest: Well.......-------- Foundation-------.. . ......... Prop. Line.......................... LEACHING LINE ( ] No. of Lines ............ :'-...........Length of each line ............ . Total Length ............ `D''Box. -- "'Type Filter-Matei l.- Depth Filter;Material................----------_---------•- --.-----------. -_..... Distance.to nearest: We �:v----------- -- - perty Line.... - oundation.... Pro ....----- SEEPAGE PIT ( } Qepth.� ,yDiamete ... _-� .,... umber- ...�------------------------- Rock Filled Yes. No❑ Water Table Depth................... , ------------ -------------------------Rock Size......... -....--------------------------- Distance to nearest: Well....... .................. ------ p/Line....-- ..... . _...Foundation................ .........Pro - .....:... REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------- ----- - --...--Date----------------------------------- ---------- Septic -- -- -- Septic Tank (Specify Requirements)...................... .---•-=-------- ------ ----------- Disposal Field (Specify Requirements)-- V �o�C� ---C r� C e.. - f r r. . ..................1c'X S_ � ............... ----------------------------------- ............ -- --- ---- ----------------- - .............. (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 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 for which this permit is issued, I shall not employ any person in such manner as to become subjec t �arkma Compensation laws of California." Signed---,.-. --- ----------------- Owner By........................ ....................... ---- ........::-------- ...... ------- ----. Title......... --------_-•----------- ...... -----......-- (If other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY..... ....... .... . - DATE .....>-- -VoI- --.-- ADDITIONLAND NUMBER ... : ...- . . DATE = _.. ...... rt AL COMMENTS...f\rSi� -te% ----------------------- --------------- . -- .....---.........-----.. . ----------........--- :.... .......................... ...... -------- ----------------------- •---•---••--••------ .-...--------- -, Date.-Final Inspection 6Y: ------- - --- - � EH 13 24 SAN J01, C3E11N LOCAL HEALTH DISTRICT Fss 216»AREv. 7/76 inn