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FOR OFFIC'r USE FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR SANITATION PERMITPermit (Complete in Triplicate) -----_------------------------___-------------------- __ 3 Date {sued__-_____�_�9�i-s3 ' ----•--------------------------_____._...------------------------ 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: Lay j�d ------'---JOB ADDRESS/LOCATION----7----- ---------------------- CENSUS.TRACT � _ 7 'iP2` UCi t.v .-- Phone------------ -------------- f - ---------- - Owner's Name ----- ---------------, , _ .; Z�� Z l 2 ----- Address- -------- ----------------- -------- _---- -------------------- ------------- CitY-------------:-_ --- -------- --- ------Zip-------------- ------- " 0ARc�/C License #. 24. 1 9-------.--Phone-- --------------------------- on 3'2----- --- Contractor s Name_---------!__'�--------1--'-- -- - -- Installation`will serve: Residence ❑ Apartment House.[] Commercial ❑ Trailer Court ❑ # Motel ❑ Other_.�uCkr ?,5 /� -R/'t-------- $oa' X 3�5 I Number of living units:----------------Number of bedrooms------------Garbage Grinder------------Lot Size.--.---.-____---_-.---...___-------------------.____-.---_ WaterSupply: Public System and name-- ------------------------- --------------------------------------7---------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand X Silt ❑ Clay ❑ Peat❑ Sandy Loam ® Clay Loam ❑ l Hardpan ❑ Adobe ❑ Fill Material_----.------If yes, type-------_______________-.--___- (Plot 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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--------------------------t:------------------------- Liquid Depth---S------------ ------ r jdoc �,! � c � _ p 2 Capacity ------- Type. P -- No. Com artments. ----- i Distance to nearest. Well__._lyV.._____-] - _- - - Foundation _._.�b-------------•Prop. Line---�0------------------- T e._ ------------- r---------------- Materia ______ LEACHING LINE' [ ] No. of Lines____-- ----- ------------ Length of each line-----------------------------------Total Length.__.jy0_____._.______._____------ „ 'D' Box--;---------Type Filter Material__---)_)/2_(h-Depth Filter Material--------0— --------------------------------------- -------- --=---------- ------ Foundation-- -------------------------Property Line-- `-SO----------- SEEPAGE PIT [ ] Depth Ce to nearest. Well__._-_ _ p Diameter-------•,-------- --Number------------------------=----- Rock Filled Yes❑ No ❑ Water Table Depth--------------------------- ------------------------------Rock Size------------------------:---------------------- t � - Distance to nearest: Well - -------• ------------- -----Foundation- ------.Prop. Line--------------------------- _ REPAIR/ADDITION (Prev. Sanitation Permit#----------- --------------------------- -------------.Date--- --------------- -----------------) Ta Septic Tank (Specify Requirements)-------=--------t=--=-- ---------------^--------- ---- --Y Disposal Field (Specify Requirements)................... -------.-------------- ------------ . 1 i -------_-----------_--------------_---___-----------_----------------------------___________________________________________ L __ {Draw existing and required addition on reverse side] I hereby certify that 1 have prepared this application and that the work will be done in accordance with Son- 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 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 subject to Workman's Compensation-laws of California." 4 Signed_ --- Owner. By` � Title----------------- -------------------- - - ----- ---- --- ------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY, -- ------- ------------------- ------ ---------------- --------------- -- DATE. c� ----- ----------------- tDIVISION OF LAND NUMBER------------------------------------------------------------------------------- f-..----------------DATE------ s_, •--•------------------------------ [ ADDITIONAL COMMENTS--- ___.. - --- - . . - . vj----- -------------- 'ii Y tJl6ty =�1-G- �- a - C(- 0T.-_ - -- ----- - - - -� 3-�^- ----- �� -- -- ---- --------- ---- • -------------------- --------------- --------- -- ---------- --- Date...-` j~1(FIns- - ecion ° ------ -----' ----- -------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 inn