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FOR OFFICE. USE: FOR OFFICE USE: } APPLICATION FOR SANITATION PERMIT t ------------------------ -------- :--------------- (Complete in Triplicate)` Permit No._ .._------ 3__ j� Date Issued_.3y3"� ,. ------__________._ _/dV--�= __.._____________._____.__.._ This Permit Expires I Year,From Date Issued Application is hereby made to the San Joaquin Local Health District for a=permif-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/LOCAT N.._--fS " / - - - Z-� ---------- � `JG_ _� . - CENSUSTRACT: -- — —P one _.Owner'•s Name • Address �'� v� c�, C71t�rN City �ZiP `:. Name. : a � 4c ��--� '�� License# � °�` Z 2 G zRhone_--- ----------------------- Contractor's -Installation will. serve: Residence 2► Apartment House.(] Commercial ❑ Trailer-Court 0, N ber.. r. Motel ❑ a Other = _. s ` 3---_GarbageGrinder-,.R,, -Lot;Size �� 1C.,f7- ------- ------------=---- WaterS of Living units------------------v Number.of bedrooms'_- apply: Public System and name------- -- -- -- ----- -- - -- - - ----- t ` - ----'---------'------------------------------_ ---- Private � � _ ' � • +lid-., Character of soil to a depth of 3 feet: - Sand Silt,❑ Glay ❑ Peat❑ Sandy Loam Clay Loam ❑ _ Hardpan ❑ Adobe❑ Fill Nlatdrial_..._.=_ _If yes, type-_-____. ::`__.___.___.__.__ (Plot 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 availablewithinf200 feet,] PACKAGE TREATMENT I ] SEPTIC TANK [ ] Size------ - k-------- -<KLiquid',Dep th.--------------------------- Capacity l------------------------- Ca acit .'Te --------------- - Material--------------------------- (�`J No. Compartments------------------Distance to nearest: Well_______ __________ ------------Foundation-------..________.`:_=----Pr'op"Line-'1. ) ---`�' NG LINE [ ] No. of Lines----------------------'---- :Length of each line.---------. -_-.___ _.:_-,Total Length_._=---_-- -_-2-----:----------------- t LEACHI .._ l D' Box------------Type Filter Material--__---------------Depth Filter Material_---------------- -----------------------------------------. 'Distance to nearest: Well_______ ________ ----------Foundation_---------------------------Property Line___._________.______ � SEEPAGE PIT j ] Depth---------------- ______________________________ Rock Filled Yes ❑ No❑ __Diameter-------- -------�- Number _. ....:,. .. _. ..._- ..._ ..... _ : . _ . Water Table.Depth--------------- --------= ------------------=------.-----Rock Size------- ------------------------------------ Distance to nearest: Well:_------i_------- ----------------------, __.Foundation--._---_---- ---_-.Prop. Line.____________.___._ REPAIR/ADDITION ]Preva Sanitation Permit t,-_-----------------------Date--__-..___.g.—_7-_7 --------------------] Se tic Tank.iSpecify Requirements)--- _______•___ - -.- -.-- ------ ---- __ .-__._ ` : Disposal Field (Specify Requireents) =..,1�� - -- --------------------------------------- .pm --- -- - - � --- - ---------------------------------- - - ------------ ------ - -----------------'-------------------- --------*---------1--------------------- : (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and tlicit'the work will be done in accordance with San Joaquin County Ordinances, State Laws-, and Rules and Regulati�fof the San .Joaquin Local Health District, Home owner or licensed agents signature certifies the following: - } a, "I certi 'that in the + k fy perform�arice�of the work for�whi�thls permit�iis issued, I shall not employ any person in such manner as [ to become subject to Workman's Com pen sationy.laws of ¢California.'.' iSigned ------------------------------------------------------ Y { Owner 13 - e.------ - --------- ----- ---- -- ------------ I -f if'other than owner] _. By Titl FOR,DEPARTMENT-USE-ONL-Y ,• _ APPLICATION ACCEPTED BY----C..-� -_- � v -------------- ---}"`� - ---------------- ---=-DATE___?-' r DIVISION OF LAND NUMBER ---------------------- - } ----------------------- --------.----------------- --.._.DATE---.-------- ---- - ----:-- --- -'. - - ADDITIONAL COMMENTS-----=---------- ----------------------=-- -------------y----------------- ---- ----- ------- --------- --------- ------------------------ - ------------------------------ ----------- --- ---------------------------------------- ------------------------------- ---------I-------------------------------------------------------------:------------ --------------------------------- - - --------------------------------------------------------- -- --------------------------------- 3----- f ----- -------- --- Final-Inspection by::-Lam- --------------------------------------- ------------------------------ ':. = == --------------- = Date. X16 / EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M 1 _