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F R OFFICE-USE:- FOR OFFICE USE:„`- APPLICATION'FOR,SANITATION PERMIT. .,, ,_.,, ------ Permit No. 3 (Complete in Triplicate) P _ __� __ ------------------------ / Date Issued. "lrS.'72 J ______________________________ /�___.__..__..__.__ This Permit Expires 1 Year From Do issued Application is hereby made to the San .Joaquin-Lacal Health District fora per it to construct.and install the work herein described. ' This application is made in compliance with County Ordinan44b. 54-9 and xisting Rules ynd_Regulations: JOB ADD RESS/LOCATION-..-l�®-J ------- :- - w`--`_---- ---V--- CENSUS TRACT------ - --------------------- i i one--------------- ------------------ Owner's Name.-.._. ._- -- Ph Address----------------------lel - 0-- -Zip------ - r r City -- .", --------------------------- Contractor's Name------- - ------------- ----- ,'` :--------- -- - License # ` Phone Installation will serve: Residence Apartment House. Commercial ❑ Trailer Court ❑ ti Motel. ❑ :Other---.'. !" ------------ r a- --- -- Number of living units:--------I!------Number of,bedrooms__Y_Garbage.Grinder-----------_:Lot.Size--- ------------------------------------- Water Supply: Public System 'and name---- ------i--/- -------------_-----_w;------=------Z-------_ -•:._-------------------------------- _ -- __Private Character of soil to a depth of 3 feet: Sand ., Silt Clay Peat Sand Loam ClayLoam Hardpan Ado e'❑ Fill Material--.-- ___.If yes, type----------- --_----------------- # [Plot plan, showing size of lot, location of sysfem in relation to.wells, buildings, etc, must be placed on reverse side.] j -- •N6V INSTALLATION:- "(No septic tank or seepage ;pit4.permitted if public sewer is available within 200 feet,] J --� - .i r - PACKAGE TREATMENT [ ] SEPTI1C TANK '[.1 Size----- - - - XS--'' Liquid Depth.:---rf------------------ L i - -WIrl : =-Material__: - No. Compartments--------' --------------------- Capacity rDis#ante to neprest: Well__._.___::_ _ __ Foundation '___, -.-Prop. , - ; } f �� _--. LEACHING LINE; ach th.___ _.__._ ----- Lines_ Length_ofle -._-_-, otaLeng s aterial. ;. ;._ ...,_.._,. YP. p _... e Filter Material+ :J_____._De#Depth Filter M 'Distance to nearest: Well_ -�,0 �_Foundcdtion-__ __`__.Property Line SEEPAGE PIT [ Depfh._,:_ameter.'____ 34_____Number_______+_____ ___________._ Rock Filled Yes eNo L] Water Table(Depth -- ids ' =- . Rock Size - S Distancelb: --- ------ Foundation--.--..-- ------Prop. Line.____ ___ ___ _______'-__. REPAIR/ADDITION (Preva Sanitation Permit#---.___:-.__.-- - _}.::. .-_ - -- ---'------ ----Date'----- ------- -------------- --- _--- Septic Tank [Specify Requirements)--------------------- _ ----------------------- Disposal 1 ---------=----=- =-------= _---- - _ � � - - � � -� � ---. DisposalField (Specify Requirements)---------------------`- -------- -------------------------- --------------------------- ----------- ---------- ---------------------------------- ---- --------------------------- ° -- ---- -------- -----------s---------------------- --- ------- - ------------- ----- --------------------------- --------------------------------- -- -. -_ ----------- ----- --------------- ---- --- ------------------------------------------------ ------------------- ----- _ -------------------- -- ---------- --- t. (Draw`ezisting and r`equ'ired addition'n"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 Ordinances, State Laws, and Rules :and Regulations of_the'Sari Joaquin Local Health District. Home owner or licensed agents signature certifles the following: "I certify that in the perfoimcince--of'the-work'for which Aiis permit is issued, I shall not employ any person in :such manner cis to become subject to.Workman' ...Compensation laws of_.Californi ia.':. Signed-:. --------------Owner BY- _ ------ --- -- _.Title _ . . : (If of er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ` / .. �f DIVISION OF LAND NUMBER._-----_------------------------------ --- -- - DATE ._ / ----- DATE:-----:: ------- � ----- - ADDITIONALCOMMENTS------------ ---- ----------•--- ------=------.------------------------------------------------:------------------- ...... ---< - ------:--------------------------------------- ------ ---- - ---------------------------:---------------•------------- -------- ----------------- ---------------------------------------- ------------ -. ------------------ ------------------ ------------------: ------- t i . . -------------------------- `' -------------- ---- - �, Final inspection by-----` -"" -------------------- --`"- Date--- ------�� EH 13 24 SAt JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M