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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE- (Complete 7-6-3 a- -------------- ( omplete in Triplicate} Permit No____________________ This Permit Expires 1 Year From Date Issued Date Issued--- �- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application is made in compliance with County Ordinance No. rddinanceNo.. 549 and existing Rules nd Reg`uI tion;� JOB ADDRESS/LOCATION USS—TRACT Owner's Name-- ----- ------------ --c�_�_.¢-�1�'-- ��21F" M�� d �8- / ---- � Phone.--------- Address ,- _ � os� Ci __ tY - ---- ------------ P----- - Contractor's Name-------- ---- _�6 A -- ------------------ __License #oxs { 5�3 Phone--------e.46 ----------- ----- Installation will serve: Residence ❑' Apartment House❑ Com e'cial ❑ T iler Court ❑ Motel ❑ Otherl�Z °p__ s,� Number of living units-----------------Number-of,b-pdrooms-----------,.Garbage Grinder------------Lot Size___-. Water Supply: Public System and name----.__----I_ ------- Private - - - -------------------------------------- Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe Fill Material-_ ___.--.__If yes, type____________________............ t (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 [ j SEPTIC TANK L�C� ' �i j Size ?�� --------------------------Liquid Depth.-.- -------------------------- epth._. -- �Ago� Capacity-----------------0__Type._Ldaldl---Material-_ -2�.�------No. Compartments.--- ---------------------- Distance ---- -----------Distance to nearest: Well --1---------------------------Foundation___ __�-- -Prop. Line-____-- LEACHING LINE [ No. of Lines_.- Length of each - ------- ------Total Length ---f:74------ 'D' Box-1------Type Filter Material-Ir—Depth Filter Material----16,-----.-------------------------------- Distance to nearest: Well__ __��_____________Foundation.=�0-°--------------- � Property Line-_..-_�------- ----------- ---�. SEEPAGE PIT Depth-17477_-Diameter._ oo `/ +QCs--------Number--------;;2-- ------------------ Rock Filled Yes No ❑C Water Table Depth--- s ------------------------------------------- Rock Size 3 Distance to nearest: Well._I'- C� Foundation �-Q- eV!-- Prop. Line-------1 f,-- --- REPAIR/ADDITION (Prev. Sanitation Permit#_------------------------------------------ ----- Date__.__________________ Septic Tank (Specify Requirements)______ ________ ______ ----------------------------------------•------------------------------------------- ---------------------------- ---- ----------(b Disposal Field (Specify Requirements)- ------ ------------- --------------------------------------------- -------------------------------------------- -- ---------------------------------------------------------------------------------------------- ------------------------------------------- (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 certify that in the p ormance of the work for which this permit is issued, I shall not'employ any person in such manner as\" to beco subject to orkman's-Compens ----------------- --------- I6ws o California." ' 1 t Signed �-.-�.--- -------Owner BY - } .. Title - (If other than owner) -` ., • I ! FOR DEPARTMENT USE ONLY Y APPLICATION ACCEPTED BY- _F ---------------------------------------- _DATE------- -------------------------- DIVISIONaz y 7 OF LAND NUMBER - DATE .�--------------------------------------- -- ADDITIONAL COMMENTS_ _. . --------------------------------- C - ---- - ------ ------------------------------------ ---------------- --------------------- -------- ------------------------------ ------ ----------------------I-------------------- L-re---------- ------------------------------- ----------------- ----- -- ------------ FinalInspection by--------------------------- - --- - -- ---- -- - - -----------------------------------Date -------- -- � ----� - EH 13 24 --"--- 4 SAN JOAQUIN OCAL HEALTH DISTRICT r&s 21677 7/76 3M t ' J