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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION�PERMIT 4� �-} e J Permit ------------------------ � ------------------------ -- [Complete in Triplicate) i Date Issued=f_:r-Z./F _ __ This Permit Expires 1 Year From Date Issued ��`� �• •--------- ------- - -------- --- - A lication is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. PP l This application is made in compliance with County Ordnance No. 549 and existing Rules and Regulat,ons;�� J17 OB ADDRESS/LOCATIC►N.,.I/., ----------- -�--._ -- = Phone- T .- _. CENSUS RAC - - A # . "- = - Owner's Name.. City -- -------------ZiP------------------------------ ---- ----------� --------- Address---_. ---- [ !�' e. Y.. . License #_ - .`�� Contractor's Name- ------ - --- =' n Pho a ------------ --- Installation will:serve: Residence ❑ Apartment House. Commercial ❑ Trailer Court ❑ k w_..- - I .� . i Cher-.4) ' Motel•❑ i O t _Garbd �e Grinder ---.._..°._ =-•- Lot_.Size � --'----- -'--��-'�s�---'--- --- -- . Number of living units:_ -- --------Number of.bedrooms; g { --- ! ---private ❑ - i E e r ---- e-,Supply: Public System:and nam ------------ Water ,..... �� ' ' ,, �; ;I Character of soil to a depth of 3 feet: Sand ❑ -Silt❑ -Clay � Peat❑ S� andy Loam ❑ :Clay Loam ❑ i '� Hardpan ❑ Adobe�i Fill Matericil�-__- ---If ye�,types- i (7 (Plot plan, showing size of lot, location of system in relation to wells, b ildings etc; must be placed o+n revevse side.)' f :._ ... NEW INSTALLATION: (No' septic tank?or seepage pit permitted if public sewer is available within 200 feet,) Size^ ' - - --- --- Liquid 'Depth - - PACKAGE TREATMENT [ ] SEPTIC TANK [ r , #_ ► Q MateriaL � �- = -No. Compartments -`------- --------- - ---- t - Capacity! 4.�. = "TYPe / - ---{ --Foundation -,14-- Distance = Prop. Line'; to nearest: Well-- I�I s Total Length ----- -- f LEACHING LINE: [..] No.,pf Lmes-__.---- --=- ------------Length of each !iris.-. .-- � --- _- - : 9 i • -- - --- 4 ' 'D' Box------------Type Filter Material - _-.,_-'`-- --.Depth Filter Material'_ Distance.to nearest: Well. ------- ------Foundation_ -�- -.. .--- ---.Property Line - Depth. Oz�-- Diameter_--. - Number-__-- - - - - j +/ - //Rock Filled *Yes �No ❑ SEEPAGE PIT [+ -- € t ° f Rock Size -------------------------- Water T ( - Table Depth---:-------- � Foundation--:'-- -�- ---------Prop. Line- � I — � . ------------ } t Distance to nearest:Well------ ---- = r ` --- ------------- ---- - ---Date----- -- -- - --=--------- ---------------- -)3 REPAIR/ADDITION {Prev. Sanitation Permit#----------------------- •, -.- �..�- •a. --------------I Septic Tank (Specify Requirements)---------------- ----------------------- -----' IL Disposal Field (Specify Requirements)------------------------------------------------'----------- ------ ------- ------ri - i.� -------------- ---------------------------------- �L ------------------------- -------------- ---------------- ------- =' " �„- _ - ----------- ------- ------------------- ------ =`- ---------------- ----------------------------------------- If. - ---- ----- - (Draw existing and required addition on reverse side) l l hereby certify that;1 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 San Joaquin Local Health District. Home owner orllicensed agents signature certifies the following: '^ em d I hall not employ any person in i such manner as "I certify that in the performance of the work'for which this permit is issued, sP•� to become iect to Workman' Compensdtioa- laws of California." y. T -- ----Ownar� s {' Signed ---- --------' -----'-- ------ .Title-- I BY----- ----------- -. (If other than o ner) FO EP TM NT USE ONLY A APPLICATION ACCEPTED BY-,-- :----' -- - ----- -- DATE. ' 77 DIVISION OF LAND NUMBER------_---------- ----------------------------- --------------------------------------------------- rt ----------------------- ADDITIONAL COMMENTS---------'----'-- -- ----------------------- ----------------- - 11 - ------------------- -- --------------- --------------------' -------- - ---- ---- ----- �(� ---------------------------- ------------------------------- �j -----------'--------- Date ----f ` EH is 2a Y l SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 216y7 REV. 7/76 3M Final inspection b` 1111