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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �' z {Complete in Triplicate} Permit No�. .--__. J hate Issued. ...�(P_-G •••-••-.••................-----........- ---------------- 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. �54�9�and existing Rules and Regulations: JOB ADDRESS/LOCATION.- ------- --4. 7- .----. CENSUS TRACT Owner's Name.- - ..... e /.y�,� - ¢. --- -------Phone'�G.L�7�� ......... Address..- ----- 8.3� -y,� Ci Zi -------- +r/� ................ . city --- - ----- Zip--------- ._------------------ Contractor's Name___/"0 '_ r ----- - - License #_-3�.�.9��_..-. .Phone.'��.1_.Oz!Q4------ 11 n.stallation -- - 11nstallation will serve; Residence% Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.-.- - - -- -- -- -------- ------------ Number of livingunits:-. __f Number of bedrooms-- ....Garbage Grinder------------Lot Size----07:��. �" �� - _.. _ Water Supply; Public System and name.- ...... .............. --------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay [] Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe R' Fill Material.. .--. -...If yes, type._ ------------- (Plot -- _-._ -. (Plot plan, showing size of lot, location of systerh 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 . y.�XS-1 _ }- 9 ----------------------Liquid Depth--y-- - ----...._.._\1 Capacity--/._o� 0.d..____Type.PA. _[�Q�__ Material._�Q��'��°-______No. Compartments .......tp, to nearest: Well-...�^-d-�...... ...... .... ...._...Foundation._./d . ...Prop. Line_.,......- . ----- �- LEACHING LINE No, of Lines c?2----------------- of each Total Length .. ./20.--.-._._--.-..----..-- . 'D' Box--- r/ . - - . Type Filter Material-.S-/.-._.-. .Depth Filter Material- ---XR.a_--........................... -------- ------- Distance to nearest: .... ........ Foundation./a.."-----------------Property Line...6-4....._............. e �r SEEPAGE PIT [�j Depth._.-a:�_-...Diameter..__ - ____ r --------------------- Rock Filled Yes No .....Number_... - •• � ., ,. Rock Size._. Water Table Depth.--------- --�-�-------------------------„,,, -------- - -- v� ��..- __--------- > - Distance to nearest: WeII.---___t^�- -�.. -------__._Foundation..�Q._r--�! 'r*�._-.Prop- Line. Distance Idle REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------- -- - -------.Date--------------_----- -------.-------_----) Septic Tank (Specify Requirements)--- ..... ---••--•--...-- - ...... i 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�'Joaglsin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: p "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 sub' to Wark n's ompensation laws of California.” Signed . . --- ---- Owrrer, . r BY------•--•-------------- Y Title.._.... ----------- (if other than owner) ORD ARTMENT USE ONLY Of APPLICATION ACCEPTED B . -__ __�.-. .. ._ _ _ DATE .f� DIVISION OF LAND NUMBER -e!II '!// --s �..- 11�:-. --- - ---- - ------ -...--------- ------....--.DATE... ------ -------- ADDITIONAL COMMENTS............. . ---------------- --- - - .... ..................... ---------- --- ----=---------- _---------- ---------- - ......... . -- ------------ --------------------- _... Final Inspection by: ------ ---- ------ ------------ - --------- --------------------------------------- ... --Date "�`_. .._ --. ...- .....-...... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&s.21677 REV. 7/76 31