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FOR OFFICE USE: FOR OFFICE USE. j APPLICATION FOR SANITATION PERMIT ................................... F (Complete in Triplicate) Permit No.—/ __-J- _ -- _ h ......................................................... This Permit Expires 1 Year From Date Issued Date Issued_~�3_-Z� 1 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 ules and Regulations: JOB ADDRESS/LOCATION : --- ---------------------------- L I�C� Cs CENSUS TRACT Owner's Name .O ------------------------------------ --------------------- ------------ - ----- -------------Phone--- 5. Address-------V_- .AV),1------ ........... - ---Cit x-� _ '.'_4........=Zip Contractor's Name - ,------ ,�--� - - -1N-1'- ---------- - License #c,_ - 9.~]- _Phone�I -0 InstallationJwill sery y bsiden3ce] 'Apartment�ousse�] Commercial ❑ Trailer Court ❑ r Motel ❑ -4 Other-----------i-------------,�---- -,-------------- m Number of living units-------- -------Number of bedrooms— -k-Garbag' md e`Gr 'er-----_----Lot Size-- -'_ -_.. � _S4�. ----------------------- - Water Supply: Public System and name----------- ---------------------------=------ --.------. A-=:------ ------- :------------------- ------------Privat r{ fr Character of soil to a depth of 3 feet: - Sand ❑ Silt❑ ClayX Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material_-__.___r_Ifyes, type---....:_.. '._----- s — -- -* j (Plot plan, showing size of lot, location of system in relation to wells;lA ildings, etc., must be placed on reverse`side.) NEW INSTALLATION: (No se tic tank or seepage pit permitted if public sewer is available within 200 feet)" PACKAGE TREATMENT [ ] SEPTIC TANK Size....V-;X-(2I0 -- ------=--------------Liquid Depth----------... '------ i Capacity_)_�QQ_ ,6_Type-____�_ ._'-:_.;_=Mate`ridl: _i►`�_ ?'a -,_No. Compartments..-„ = � 5 �s Distance to nearest: Well_:.- _V � �- .._ . oundation ___ __Prop. Line_ c, - ___- LEACHING LINE �Q No. of Lines_:___,_ _ _- __.% '---�, ofa'I'Length � .... �,r ._.�.--„-Length of.each line__.___ 'D' Box----I------Type Filter Material-1-1jYS4Ck Depth Filter Material_ ------------------------------------------_-------- 411 1 Distanceto nearest: Well_-_ _� 4_+_-�t--Foundation: .. .-` _. T _______ 1 ------.Property Line_- Q SEEPAGE PIT [ ] Depth-----------'----Diameter-------------- -----Number--------------------...... -- . _-- Rock Fi ll6d Yes.ElcN° i Water Table Depth-------------------- ----------------------------- --- Rock Size---- --------------------------------------- -- Distance to nearest: Well---- ------- -------'--------------------Foundation.---__---------------------Prop. Line---------------4y._.-----. REPAIR/ADDITION (Prev. Sanitation Permit#.-_- Date._.._._..:_ .................: . . -----=------ --- -- Septic Tank [Specify RequirementsE---------------....... ..... ... .. .. .----------------------- --------------- -- ----------------------- Disposal Field (Specify Requirements)---------------------- ------------------- -------------------- -----------------=`------------------------ ---- - ---- ---------- --------------- -------------- ------- ----------------------------- -------------------------- ---------------- ---------------------------------------- -------- -- ---=-- --- --- -- -----------=--=----- ------------------------------------------------------------------=--"--=------------- ------------------------- ---------- --------- (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 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom b' t to Wor Compensation law Cal' ornia." Signed--- - Owner t BY-------- ------------- ------------------------- ----- Title--------- -- ----- (If other than owner) i F FORP DEPARTMENT ME Y” APPLICATION ACCEPTED BY L ____ _....-. .. --- - - ' .a--- DATE.../o -- �.- �- --- ------- DIVISION OF LAND NUMBER.. - ------------------------------- DATE ADDITIONAL COMMENTS-------------------------------------------------------------------------------- -- - ----- ---------------------------------------------------- ------ ------------------- ------------- -- ------------------------=---------------------------- ------------------- ----- ---------------------- I ------------------------------------ = ----- --- - � ----------- Final Inspection bY:- ;'l fj `---------------------- Date. . EH 13 2a SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76�,aan, i