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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _._ _-_1./!-7 ___--- --- ------------------ --------- Date Issued__/ --------------------------- --------------------_-_- -_ 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: A JOB ADDS/LOCATION_:_:_� ... -r-------- -----'- -------------- ---/ '.- CENSUS.TRACT ' r - Owner's,,Name->- ---- -lam l/P � - , ✓'honei '�'r�� /� =------- ----------------------------------- - -- ----- -: ----------- Address-------- --SSU¢-- S. C �- '-- ------------- ---City-. f � ' - Zip ��5�3�(� } Contractors Name-----Ty-,-1 ---•----A I-G�j rA�.Sdr+------------------------------------License .#_ � -- -? ----Phone-e�_3 I r . Serfs-lis` ' Installation will serve: Residence ❑ . Apartment House.❑ :Commercial. - Trailer Court ❑ l Motel ❑ Other--- .. --------- -'-- ----- ry Number of livingunits:----------------Number of. bedrooms_`------ -Garbo a Grinder.-..........Lot Size------d5� __ Z P t is Water Supply: Public System and name f .: ---- ---------------------- -------- --------- -- -----------------------------------Private" Character of soil to a depth of 3 feet: Sand 'Silt 0 Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe:❑ Fill Material-------------Ifyes, 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 fank"6r seepage .pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT- { ] SEPTIC TANKn Size-----------------------------------------------------------Liquid Depth--------------- ,--- Capacity-_�- �, Typef�!'�EZs�-----Material--- Compartments---- ------------------------------- � Q Distance to nearest: Well---- -e- --------------- 'Foundation------Zy---- -----Prop. Line-------- -i LEACHING LINENa, of L'ines.-----__'_- _ .7-------- Length of each line.-- .. ------------------Total Length ..... ------ 'D' e. 11 Box.--�S - TypFilter Material-_/Pa�---- Depth Filter Material-------�--------------_----------------------- _ ,. --.-- Distance:to nearest: Well-,- Ob_�____-Foundption- 4 %0 -�- Line_- -_---��_--- 3 .._,.__4- ------- - ------- Zr- ----- -------- -- SEEPAGE PIT [ ] Depth----------------Diameter-;-------:----- -----Number..._-------------------- t Rock Filled Yes ❑ No ❑ Water Table Depth--------------- -----------------------------------------Rock Size------------------------------------------------ ; 1 Distance to nearest: Well---_-------------------------------_----- Foundation_------------------------Prop. Line---------------_-----------. REPAIR/ADDITION (Prev. Sanitation Permit#----------------------.---------------------------.Date--------------- Septic Tank (Specify Requirements) ------ -------------------- ';ti t--------------------------------- ----- ----------=-------------------- ------- ------------ Disposal Field {Specify Requirements) "`"R = =-= ==-------------------------------------------- --------------------------------- ------ - — --- ------ -----------------�-�-`------- ----- ------=------------------- ------.----------------------------------------------------- (Draw ---------------- ------------------------------- �t --------------------------- - ---------------------- - - -- - (Draw existing�-,-gnd required-addition on reverse side) I hereby certify that,] have prepared-this application-ncl that-,the-work-:!will-be-done in-accordance with San Joaquin County Ordinances, State Laws; and Rules and Regulations of the) San-joaquin:;L cal health District. Home owner or licensed agents signature certifies the following: "I certify- that in the performance of-the work far'irohich thispermit is`issued;F sFiall not employ any person in such manner as to become subject to Workman's .Compensation laws of Califoriria." j7 Signed---- '�- _1. ---Owner By- / •arlr --- A_ ---..Title- (If other than:owner) F i ' FOR DEPARTMENTUSEONLY APPLICATION ACCEPTED BY:_.__ - — `---- - -- -- - --- --=------------------------------- --------------------------DATE. .. DIVISION OF LAND NUMBER----------- --- - ----------------------=------------- - - -------------- --- -----DATE- ---- -------- --- - ---- ADDITIONAL COMMENTS----------------------- -------.------------------------------------- = = i --------------------- - _- y--- ----- ------------------------ -'- --`--- - - -y'--- i = ----------------------------------------------------------------------------------------- --------------------------------------- - ---- ------------------------------------------ a' --- r - -- ------------------------- -------------------------------------- Fin ----- Final Ins ection b r-- � --- --- --------- _ ` P Y --------- -_T _ . -�`- ----Date f= EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M