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I FOR'-OFFICE USE: FOR`OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------- -- (Complete in Triplicate) Permit No..-.�__T._.-.--.- -------------------------------------- -------------- y --/ a,' 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: '2-0 JOB ADDRESS/LOCATION. l `� C -------- - - m._a_=.-.CENSUS_TRACT Owner's Name.....J`.------- 40_XG----------------- ------------------- ------------ -------Phone-------------------------------------- -------- -Address----- sz . . . 2 --- ---Ci /''w 7�------`3----------- --Zi Contractor's Name----- � --1 4,r/_L.15r License # P_ �_3"5.n_,Phone_a3. ------------ Installation will serve: Residence g Apartment House ❑ Commercial ❑ Trailer Court❑ Motel ❑ Other---------------------------------------------- 1 i Number of living units:------!____.---Number of bedrooms_-,3-----Garbage Grinder-----_-------Lot Size--- ._.,y -________________________ Water Supply: Public System and name--------------------------- --------------------------------------------- ------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam W Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material------------If yes, type---------------- 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 available within 200 feet,[ `f 0 PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size____J- -a------------------------Liquid Depth...-_'________.__ Capacity�Aep-.-.----Type --'� -----.rMaterial__________________________No. Compartments-__-_- .--4 U Distance to nearest: Well-_.._-L00-----------------------------F�oyundation.-L0______-----.------Prop. Line-------------------------- LEACHING LINE [ ] No, of Lines-_t-'3---------------------Length of each line----/f ---------------------Total Length -----A-10---------- op j per, // -------------- 'D' Box-_4.--k-Type Filter Material 1v4xi-�' pepth Filter Material--------!_/__---_------------------------- Distance to nearest: Well-IIA! --------------Property Line.-..-13-0----------------------- - 1 SEEPAGE PIT j ] Depth.----------------Diartieter--------------------Number---- --------------------------- Rock Filled Yes ❑ No ❑�3 Y ` Water Table Depth---------------- ---------- -----------------------------Rock Size------------------------------------------------ Distance to-nearest.. Well -----------------------------Foundation--------------------------Prop. Line--------------- ----- ----- REPAIR/ADDITION .---- ------ REPAIR/ADDITION (Prev. Sanitation Peimit#:r-+_----------------------------------------Date______________________----__.--_.-.---------) Septic Tank (Specify Requirements) ^` ---------------------------------------------------------------- -------- --- ------------------ ,� .. DisposalField (Specify Requirements)--- - --------------------------------------------------------------------------------------------------------------- ------ ------- 1 Y (Draw existing and 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 Rules and Regulations of the San-Joaquin Local Health District, Home owner or licensed agents signature certifies the following: i% "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become,subiect tt Workman's 'Compensation laws of California." Signed------ ! �+' 2/. --------Owner --- '---- ----------------- ------------ --- ------------ -------------- ---- Title------------- , ----------- ---------------------------- (If other than owner) 'FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- --- ---- - -- - ----DATE -----------------__-- DIVISIONOF LAND NUMBER---------- --- - ------------------------------- ------------- -------------------------------------DATE.------------- -- ------------------------------ ADDITIONALCOMMENTS------------ %----------------=f-----'-------------------------------------- - --------------------------------- ------------------------- s _ 1 - --- , -------------------'- - -------------------------------------------- --------------------------- -•---- - -tx.:---. ------------_----- ------�-- -------------- - � --------- ---- +- - - FinalInspection by---------------- -- --- -- ----- - -- -------- ----------------------------------------------------------------Date...-�---LJ-_1-- X0--------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT rss 21e77 176 3M r