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F FOR OFFICE USE: FOR OFFICE USE: 4 APPLICATION FOR SANITATION PERMIT (Complete in,Triplicate) Permit . dti •----------- This Permit Expires 1 Year From Date Issued Date Issued_lQ�/9.'--7� 4 Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. y This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: i JOB ADDRESS/LOCATION_ ,. , ' X�- CENSUS TRACT-- - --------- ------- Owner's Name-. - _- -- -- ---- ---------------------._.----- ----Phone,-_6F �-- Address-----!-23_ ,3 - Y c3 --- --------------- --- ------ -----------ZiP ------------------ . it -- - -- Contractor's Name - = ------- -=- --------- --.- License #_3 �7,o-21 Phone... � ------- --- ------��- Installation will serve: `, Residence [� .�artment House.❑ Comi•nercial -Trailer Court ❑ t fi. '• Motel ❑ Other_ F e - .-ts� Number of living units: Number of bedrooms_ g Size_._ _____ _._:_._-`------_-._.- --- __Garba a Grinder__. Lot Water Supply: Public System and name--- ---'--.-,---''.---------- - ------- _ .: --------------- ----------- - _ - -- ------------:---------- - -__Private' I Character of soil to a depth of 3 feet: : Sand n Silt❑ Clay eat❑ Sandy Loam ❑ Clay Loam i .. dHardpan ❑ Adobe, Fill Material_____________If es ► ; Yes,type IPlot plan, showing size of lot, location of system in relation to-wells, buildings, etc.mustbe placed on reverse side.) NEW INSTALLATION i(No'-septic tank'or seepage pit permitted if public sewer,s available-within 200 feet,) _ PACKAGE TREATMENT=:[�]' SEPTIC TANK {[- Size ' _ z-Y—;l Zl-t.--�� , �" /� ,� //�� --- ---------Liquid Depth------- --------- t Capacitylrl®© Type-- ,------.Mutenal c_�rc� '--------No. Compartments-------------"`-------------- } �,-- Z I Distance-to nearest:Welln�of;each•acne----Fou ��aion _,��____----------Prop; Line_ LEACHING LINE [y'No. of Lines_ _ -_ ` Total Length _-. ,�.7c -� j �+ $ #D' Box/ . -Type Filter Material .l �lZ_:beptf Filter Material_ _-_____-____ ------------------------------------ D si fence#o nearest: Well:__2 - .Foundation.�l --Property Line_. _____ -- SEEPAGE PIT [ -]�'� Depth`--_ Diameter_'_-_ f!- --Number---=____ _ ______ { Rock Filled Yeses,, No❑12, Water Table Depth.---'.-Z = ' ' Rock Size f ri••X �/� fl s ---- .. �. CEJ / �. ` • - F Distance to_nearest: Well .._ Foundation .. --� ` ___.Prop.' Line ___ 1 may' REPAIR/ADDITION Prev. Sanitation Permit#_,________________ Septic Tank'(Specify Requ rements).___. ¢ " i Disposal Field (Specify,Requi(ements)------;2�, -- --------- " - ------------ . t y -- --------------------------------- -------------- - ---- -------------- - . ._ _ .- k - t w :: ... . --IDraw existingond required 'addition 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 Rles :and Regulations of tr they; San Joaquin .Local Health District, Home owner or licensed agents signature certifies the following: T_ . „ k I l "I certify that in the perfo-rmronce' of`the-work for which this permit is issued, Ishall riot employ any-person in such manner;as to become subject,..to Wor mans,Compensation,.laws-of-California." Signed I ----- -- ------- .. . . = ._ -.--- s_-----'Ow Owner r r - BY f / ------------ ------------- ---------------Titlef_- " (if other than.owner) I FOR DEPARTMENJ USE ONLY APPLICATION ACCEPTED BY...r ' =_-==--'---- --- --------------------- -- DATE..- - ,6). /- DIVISION OF LAND NUMBER.,--- ---------- - - ------ ----------------------- ---------- ------------- ----- - DATE_----------- _ - ADDITIONAL COMMENTS-.; - ----------: -----{------------------------------------=--- -------- ---------- ----------- ---------'-------=--- = -------- ------------------ -------------- --=-------------------- ----------------- -------------------- -.. .---------------- ,. -- -------- --------------------------------------------------------- .------- --- ----------------- --- ------------ --------------------------- --- ---------- --------------- Final,lnspectior by y�1 = `_ "' l ' 1 "_ 6 = Date.. = N .... ------ ia_za SAN JOA IN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M `''""`