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a x FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT iComplete in Triplicate) =o Permit No----------------------- Z� � A Date Issued_ .116-_ ..v .O 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. Thisapplication is made in compliance with County Ordinance No. 549 and existing`Rules and Regulations: JOB ADDRESS/LOCATIO __.�-f��7_-f__------------------------------------------------------... _ -� i [ r _ - ---.CENSUS TRACT. - ----- --- :---------- /,? l�__e i Owner's Name- :---._ Phone_5�-- Address - - - -------- --------- --- -- ------ ---City - ----------- ------ --"-------------Zip---------------------------- :_ ' f --------------------- Contractor's Name - -- :---- ------ � •------------ --------------------- ----- License # -----Phone--. .�_.�_-�-�--------- ------. Installation will serve: Residence [X Apartment House.❑Comm_ ercTal ❑ Trailer Court ❑ # i Motel [] Other_ .:_---------- r _f Number of living units:--. .-----Number of bedrooms-.----------Garbage Grinder_:_1 3__=$_Lot Size______�.�_a _-____.- Water Supply: Public System and name------- ----------=------------------------------------------------------------- ----=------ -------------- ---Private ❑ Character of soil to a depth of 3 feet: • Sand ❑ Silt [I Clay ❑ ; Peat E� Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe`, Fill Material If yes type---:_s----------- (Plot plan, showing size of lot, location.-of system in relation Tu-wells,,buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic :tank or seepage'pit.permitted i public sewer is available within 200 feet,) R �' . PACKAGE TREATMENT"[ ]'�-SEPTIC TANK[ IL - Size__ _____--___-___ ___________ _____Liquid Depth,_ --------- k (Capacity Type = = Material---------------`--------No' Compartments------ -- ;------------------ i Distance.to nearest: Well`-----------------------------=-------------Foundation___---- •-------------__Prop. Line---------------------------- e LEACHING LINE. [ ] Na. of Lines--- of of,each line.______. _.____�_____._-----Total 'Length------------------------------------- _ 'b' Box-------------Type Filter Material-----------------------Depth Filter Material-_----------------------------------------------------------._-- Distance.to nearest: Well_=--------- ___ ______ _>`*Foundation_._F_.._____ _ _ -.Property Line------------------------------- SEEPAGE PIT [ ] Depth-------------------Diameter--v__.__. --'---- ----Numkier---- ---------------,------*'' Rock Filled .Yes E] No E] Water Table Depth----------------- --i __ Rock Size3 _______________ Distance to nearest: Wel•l_- ._-__--___ �-- w''Foundation-----------------------___Prop.-L-ine_______-___--_-_ ) '----------------- REPAIR/ADDITION (Prev. Sanitation Permit ----- --------------° ----------_Date '--_------------ ------------ r----------- ---) f - -- Septic Tank (Specify-Requirements) ---- ------ ------------ t = " `"" - Disposal Field(Specify Requirements)_:.____. __ _ .a ------- ----- ------------ --t�L--- ------------------------------------------------------------- ----------- - - -__- ___-__-, i . ------ = 3_-5,= X ar_t-cx,� - ------------------------ -------------------------------- r T { (Draw existing and iequired addition on reverse side)'T ; I hereby certify that I have prepared this application and thatthe'W'o' rk will be done,in (accordance with San Joaquin County Ordinances, State Laws, and Rules•and Regulations of tH 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 thisTpe.rmit_is_issued, I-shall not employ any person in such manner as to become subject to Workman's Compensation laws_of. California.'," Signed---------- ------- -' -- ----, Owner /l - $Y�t ) ----- -- -Title ---- ----- .--------- ------- -- --- -------- ------------------------- i Cher than owner ,. ,. t ^FO DEPARTMENT USE ONLY \� S01 APPLICATION ACCEPTED BY ___ - = '` -- ------------------- ---DATE,---- - ---------------- ADDITIONAL COMMENTS ----=--- --------- - -- -- --~ -----�'-��-----�--4� ------------------...------ = -.DA = ---:-- °. ---. :---------- -----------�--- DIVISION OF LAND NUMBER,__„__ „-_-. --- ----- -----4-------------------------------------------------- ---------------- = - --- - ---------------- ---------:---- -- - ------- ------------- ---- ----- -- /�- _ lJ �f f f G � �::-------7-/-- -------------------------- --J- --------------------------=---------- - ------- --- ----------------------------------- --------- ------------------------------------------- Final Inspection bDate------ -- EH --_3-_--- __-- 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT E&5 21677 REV. 7/76 3M