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FOR OFFICE USE: FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT .................... .. ...... .... _ p p ICom lets in Triplicate) Permit ...... Date --------- ........ ... ....... This Permit Expires I 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/LOCATIO f. ..... -------------- ------- ........ CENSUS TRACT-------------------------------------_----- . e , Owner's Name..----. r�. 31. .677 q .- Phone--T�-- 1/ Address.------ P�7�D.0 . . .. .. ....... . ...... City - ------- y•J .....-.--zip... �'�, ................... Contractor's Name_... . Installation will serve: ResidenceApartment House ❑ Commercial F-1Trailer Court ❑ Motel ❑ Other .................. .. . ..... ........ --Number of bedrooms. ........ Number of living units:.......'/.- _ j16-arbage Gri de4......._....Lot Size ........ .............................. Water Supply: Public Systern and name... . . .. .1(.0 !^,.r..- 1"<- ............... .......... .......... ............. ------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............ ---------- ------- (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 [ ) SEPTIC TANK [ Size......... ... ....... ._ .......Liquid Depth.'Q'S... .. . . .. .... tt^^''1l,, � � -.s Capacity.. ., f Type.1310.Ck....--.....Mate.rial... 1,M s------- .No. ampc�Yfirents_.. > -------- �. Distiance to nearest: Well--.-..._k1. 1j4---------------------.-.Foundation .-. 4-. . ;Prop. Line- 14 ---- --- ---... LEACHING LINE [ ] No1of Lines............... . .... length of each line . -- .Ct-.---. - + Total; Length......41,?-t---.--.---.--.--- 'D' $ox_.� _._. Type Filter Material,,- 5...... Depth Filter Material ...f '`r 1 " . Distance to nearest: Well-.,AI.IA........ ......Foundation. .c?47.._ Property Line....16------_---------------- SEEPAGE --.._..-. _SEEPAGE PIT [ ] Depth................Diameter....................Number------------ .................. ; ! `.Rock Filled Yes ❑ No ❑ Wafer Table Depth......--------------------- ----------- -----------------Rock Size ... :... .... ....... -- •----•------- Distance to nearest: Well_ ................................ . Foundation ... . ... ' Prop. Line------_-------------...... REPAIR/ADDITION (Prev. Sanitation Permit#....... -----------------------------------........Date.........._...__.._..��..:.._..._-__._._'_..[ Septic Tank (Specify Requirements)...... ..... . .....:............... -----.---................. Disposal Field {Specify Requirements)-.- --------------------- ---- I (Draw existing and required addition on reverse side) %A I hereby certify that I have Irepared this application and that the work will be done in accoi0ance with San Joaquin County Ordinances, State Laws, avid 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 become subject to Workman's Compensation laws of California." I .. r Signed '. 'n'... ....t..- ---• -- �, �r� r j .._- .......... ---..Owner i f By__............................. -... ------------ ---- ....................... ...........Title..... .. -----•-- ----------------- .............. (If other than owner) ) FOR DEPARTMENT USE ONLY APPLICATION,ACCEPTED B _ -._-- -- - - --�------._....E-•:...�......................,�x � � .��,.- -��;�Lal <:-�- -.._.DATE ..�.:�{`./�.�.......----...._....._. .. DIVISION OF LAND NUMBER. ----- _.. "�'� ' � '� � � " u""�" -DATE.-."'"—'.__." .. r --------------- ADDITIONAL COMMENTS ................ ---------------- --- -- -- -------------------------- -------- --------- --------------------------------- ------------------------..---- ------------------ .......................... ----- --------- �---------------------------------------............... ------ Final Inso.66on b •--------- --- ------Date................. .......- .............. E+1 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 3M