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-e-'FO'R OFFICE U5& FOR OFFICE U$E: APPLICATION FOR SANITATION PERMIT r ----------------------------------------- (Complete in TriplicatQJ Permit No.____g___.,3 _-3 Date _________________________________ ------------------------ 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 ��.�17--- `. C; - ------------------ , 4n A �� -_ -.^. CENSUS TRACT-------------- __--- Owner's Name -l/ �r7.r�).'. --- ------------------------------------------------------------- ---- --- ---- Address -- Phone- _.J =+ l+�l r� Address------- /.---------W.---- -- ------------- - ------- - - ---------- -------City s C_ Zip Contractor's Name------ :--- -------------------------=---------------------License # --�� .----Phone_, Installation'will serve: Residence�K Apartment House.❑ Commercial E] Trailer Court F1•r Motel ❑ Other.---- -- - ---- --- Number of living units ----------Number of bedrooms-,'/" e Grinder------------Lot Size -. •. _ ��------- ----------------------------- Water Supply: Public System and name - r ..- Privateg� Character of soil to a depth of 3 feet. Sand ❑ Silt❑ -Clay [7) Peat❑ Sandy Loam 0 Clay Loam 'f Hardpan ❑ Adobe ❑ Fill Mater�al__.. A-_..-If yes, type-------------------------------- ' } (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on relerse side.) PACKAGE TREATMENT' SEPTIC TANK .i Size_- tic sewer is available within 20 feet,] a !7 { ] [ 1 t NEW INSTALLATION: (No septic tank -or seepage ipit permitted if public sewer� � /� Liquiid Depfih.-_.___._ - Y (, t p y.1�6V-------TYPe - C_ Material--- ---No. Co partments- = -- -------- ---- _ S C a acit ---------- istance to nearest: Well:_ . ____ i -.--.-.1 -- __ I•Foundatio _ ____ _______.Prop. -Line___ __ __._---._ ; LEACHING IN [ ] No. of Lines.____. _________________4Lengthof each_line- -_ _-----------------1Total Length�'_ ® _-- ---_ _ i VD' Box -- - -T e Filter Mat Ty'YP h�Filter Material------ ----- ---------- -------------------------- --- �'Distance to.nearest: Well p4__✓T ., _Foundation-___�Q__��_____-Property L`-ine---r 0_ - SEEPAGE PIT ( ] Depth______----------Diameter._______--__-_i---.Number------------------ ------------- Rock Filled Yes ❑ No❑ Water Table Depth P .'"= rfn `= !Rock Size r-------- ------- et 1 Distance to nearest: Well-'---- -- ---------- -- 'Foundation---------:-----------------Pro _ Pro- p, Line_.____----__---- --- --_-- { REPAIR/ADDITION (Prev, Sanitation Permit#------------------------------- ---------------------------------_------ -.---} Septic Tank(Specify Requirements)-------------------------- ---------------�.---_ a e-\------------------------------------- --------------------------------------- Disposal Field (Specify Requirements)----- - ------------- ' ----------2- ---- ---- -- ! \ *: ----------------------------------------------- ---------------- -----------------------------------_ ------------- ---- ---- ----------------- 3 l! . 4 (Draw existing and required addition on reveirl� side) I hereby certify that I have prepared this application and-that-tye;�work-will-be wdone`4n accordance with San Joaquin County,: Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heal th`District, Home 4owner or licensed agent$ signature certifies the following: "I Certify that in the performance of the work for with this permit is issued, I shall not employ any p rson in such manner as to become `subject Wor an's Co pensation lames of CaliFornia." Signed-------' - ---- -----------Owner I ` BY -------- --------------------------------------------------------------------Title------- ----- ------------ ------------------------ (If other than owner) . WK DEPARTMENT USE ONLY APPLICAT DIVIS:ONIOf LAND NUMBER.--- - - _, - -------------------------------- ADDITIONAL COMMENTS------------------------------_-- - -------- ---- --------- ---- - ----------------------- ----------- ----------------------------------------------------- ! 4 -------- -------------- - Date.-------------- -- -�--- j�-------------- Final Inspection by:- . ---- ' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7/76 3M i C,7?