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f FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No---------------- ----- ------------ r Date Issued_2=-/-------77----- --------------------------------------------------------- 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: JOB ADDRESS/LOCATION, : .- { 't � " -- -----'---- --- CENSUS..TRACT--------- r -- ----- --- Owner's Name------------- .�-�. f- -'--U - v - -' i------- --------------------------------Phone Y -------- Address------c7_20-------- •---- / //� x - City- so ._ 47_ -�----Zip: �� rte----1------- { / rev .max v� Contractor's Name---- .f_.L fi`Uf=�G= '-------------------------------------License 26 PFiorie'. " - Installation will serve: Residence ❑e `Apartment House Commercial ❑ Trailer Court ❑ Mote! ❑ Other-------- ---------------------------------- Number of living units________ _______Number of bedrooms------------Garbage Grinder.-----------Lot Size_______ _____—----------------- Supply: Public System and name--------------------- ------------------------------------------------- -----!?--- ----- ----- -- ------- x---------------------Private EK Character of soil to a-depth-of 3 feet: *Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ak r T THardpan Q Adb-be ❑ -'Fil Material-- ---------If yes, type----- ----- ------------ --- � •• [Plot plan, showing size of jot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] k NEW INSTALLATION: (Np' s ptic.tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK t-]--- Size------------------------------- -n--------- --------------PLiquiO Depth---------------------------• t r ` r Capacity -` Type---------------------- Material --No. Compartments - � istacto nearest ;1Nelf______________________ _____ _ _ �. tDne.,, I • - - - - ----'------foundation---------------------------Prop. Line---------------------------- LEACHING ----------------------- --LEACHING LINES ,[ ] No-of Lines----- ---------------- Length of each line--- -----------------------------Total LengthA-------------------------------------- ' r DBox.-,----_1---Type Filter Material- ------.Depth Filter Material--------------------- - -------------------------. �. _ � r J `Distance o,nearest: Wei l----------------------------Foundation----------------- ProP erty Lne----------------------------------- SEEPAGE PIT { ] D pth_l_�#___-'__.Diameter_________________-_Number_.___________ _____________. _ Rock Filled Yes ❑ No ❑ �' ' Water Table Depth"___-__-_____.__-_ Rock Size--------- }- Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line----------------___ REPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------_-------Date---------------------------------------- _____] �__. .¢ I > SepticTank (Specify Requirements)----- ---- ---- ---- ---- ------------------- ---- - ------------------------------------------------------------------------------------------ --- Disposal Field _(Specify Requirements)_.____ .+•'"� , t.._ ,_._11f_Lir___._ AT; - --------- - = ---------------------------------- - ------------------------------ ---------------------------------------------- ----------- -------------- ----- 'pN (Draw existing and required addition on reverse side) # + I hereby certify that=l ,have prepared this application and that the work will be done in raccplance with Sait,.Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents i signature certifies Nie following: "I certify that in thepe ormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject-t o ns C _�nsatlor* laws of California,`„, Signed ----- ------ ''w`._Owner r' { i + _ 4 a t j --------Title -------------=--------- (If other than owne�� _ .�...r ---- [ I F FOR D ARTMENT USE ONLY I ACCEPTED BY---- -- -------------- ------ DATt~..-`:��/ -------------------- APPLICATIOND VISlC N OF LAND NUMBER. - j:�. DATE-.-- ADDITIONAL ATE-.- �_ .. ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ' . -------------- ---------------------------- --- ------------------------------------------------------------- 1 -------------------- ----------------------------- --------------------------------------- -------------------------- Final Inspection-by:--- -- ---- ------------ ------------------------------- - ---Date.------- EH 13 24 SAN J QUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M