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FOR OFFICE USE: '1- ` ' 1 � APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No____ This Permit Expires 1 Year From Date Issued Date Issued_ -F' Z t 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 compliancOrdinance No. 549 and existing Rules and Regulations: .,._ JO` ADDRESS/LOCATIQ ___-- - ----?r�-- -- - =- Owner s Name - 96e ._. Address ----------- - ---------- ------------ &I, -- -t --- �tY P ' Contractor's Name:_'______ _________ ___ .' cense# hone 7 ' ` Li � - Ph rod ' Installation-will serve: Residence ❑ Apartment Ho e ❑ ComrcLa Trailer Court, E] ! - Mote! [� Other-,c, =JX- s ; i Number,of living units:_ ------ ------ of.bedroiims Garbage Grinder_.<------ Lot _ ------ Water Supply:,Public System and name _ - ------------------------ -----------Private; , "} Character of soil to a depth of 3 feet„ Sand'Ej'�Sift❑ Cloy ❑" "Pea 0and "� Sy Lom❑aClay Loa ❑m _ w__o Hardpan F-1Adobe❑ Fill Material____. If es, e x i Y tYp - -- - is (Plotlan, showin �t p g size of lot, location of;system in relation to;wells, buildings,',etc.imust be placed on reverie side.) 11 NEW INSTALLATION:' [No'septic tank or seepage pit permitted if public sewer is available within'200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK . [ ]. ,.._ s. �: -Size---- I-----I------"° - - s,-- - � r - � ---- Liquid D �-- --- - - epth • . F Capacity -------- --- -:=Type_=_ -�W Material--:._ No.` Compartments .�..,Dist.nce;to nearest: Well- r = ;:: -.F o Pr p e . undation f ] ) c � f LEACHING LINE' [A . No, of Lines-._._..____:____ __,,-:-,,,,.Len of each line._T__ TotalyLength o r ° -------- ------------ Box_.____.___Type Filter Materials----.____._______.Depth Filter Material.___---- .__ t ----- -- ----- { t Distance to nearest: Well __ __-___. Foundation _,___. :_____ , Property Line_______________________ j �... .,. .... x_ . .,_ ._-.�.....-1. .. % N SEEPAGE PIT [ ] Depth-__F._______._Diameter."______'__.___-_ Number-------------------------------- A Rock Filled Yes ❑ o � Water Table'Depth---------------- = = ---- -----.Rock Size------- ' = - Distance to nearest: 1Ne11-------------------------------- Foundation--------- -------$- Prop. Line.- --- r--- ` 3 • REPAIR/ADDITION (Prey' Sanitation Permit#:_]---:`'_-::�_: ¢ �- _.Date:" -- ", --- -.- ---- ---.-------------- ------ Septic Tank (Specify Requirements). _ = ----------------------`--- ---- - - ----L---------------- ............ Disposal Field (Specify Requirements) ---- � --- �L Kr-'r i__ . `._. - -------------= 0-f _ '1� (Draw existing and required addition on reverse side) , 1 hereby certify that-1 have prepared this--application-and that'the L.work will- be-done in accordance with San Joaquin County � q ty � Ordinances, State Laws, and Rules and Regulations_ of:the! San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "I certifythat in 'the � ._ j_.. __ .�. '• = :. -. . performance oF'the work fo[which this permit is issued;'1 shall not employ any person in such manner as to become,subject to Workman's Compensation t-.laws.-of..Colifornia.':_.. "t,.- .t { Signed "^ � � _ ---- --- --- - --- BY !" �T J - - ------- -`---- e -- - '�- --- - �" _;Own - Title ____ (lf other than .owner) r -r.,-.._r.._... _ .,,. ,a.... �..�_. .. "i:.. a -'FOR'DEPARTMENT USE ONLY` *"' T- '* = APPLICATION ACCEPTED BY-- - 4 DATE.` � , . -------- -------- DIVISION OF LAND NUMBER._ ------------------x------------------------------- ------ - ATE 3 ADDITIONAL COMMENTS --- - = D #. — r ----------------------------------- -- ------------------- - - -- ----------------------------------------=--------------- ------------- ----------------- f ----- --------- --- ---- ----- ---- --------------------------------- # -------------- ----- --------------- --- , f r Inspection71 by = ` ----- ----- ---------t. ='---- " Date. Z S ' SAN JOA QUW LOCAL NEALTN.DISTRICT F&521677 REV. 7/76 3M r A