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FOR 0FV10E USE: APPLICATIOlt-,FOR SANITATION PERMITFOR OFFICE USE: ---------------------------------- - - Permit No.._ /- (Complete in Triplicate) ,I Date issued_._._�'�_`". , ----- ------------------------------------- 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 madeinc3mp9ance with County Ordinange No. 549 and existing Rules and V2egulations: JOB ADDRESS/LO ATION_ . �-------------------- --- _ _____ ____ ____ ;_,.. _ ._ f_L : .�"..CENSUS TRAC Owner's Name. r -------- '/ --------------Phone__. J_ _L..... f Address.- .78-616_. l i �� "t7�� - - -=---- -------------------=------ C ty zip --- Contractor's Name---- �G�1 -- - _--- - - --f------- -.. License #. � Phone------� �'[� � e Apartment House.❑ Commercial ❑ Trailer Court ❑ 4 Installation will,serve: Resident' otel ❑ Other --------- :_________________________�._______ tl - Number of living units:---.----1____"Number of bedrooms:--3---Garbage Grinder mot Size----J_ /sp._, -------------------- Water _.__-__----- --_Water Supply: Public System and name---- f1-------- - .-- ------------=------------- -------- -------.------ fl--------------------------- --- _-- ----.-:--------_--Private Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay' ElPeat E] Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe Fill Material------__-�..If' e�;typ !T $ [Plot plan, showing size of lot, location of'system in relation to wells, buildings, etc. must be placed on reverse side.] I NEW INSTALLATION:.. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] 4 �, _ � r /� a=f N PACKAGE TREATMENT ['] SEPTIC TANK [ ] Size____________ __ l Liquid Depth. ° a / I YP -----------No. Compartments_'__-______._ --- tr . Capacity- ��•�__T e.- .---------��flillaterial----�---------- �-r"- x Distance to nearest: Well.---------j-_L./----------------------____Fou dation__.==/_ ._.:._._ =_i_.Prop, Line--- -------------_ y LEACHING LINE [ ] No. of Lines " -----------------Length�of�each ach line._ i-- p------___--Total Lentgth./-/--- - --'------ .'D' Box----- _ _. TYPe Filter Material, DePth Filter Materi I--_---.__ __________________ _--- l ; --------------- Distance to newest: Well-------(2.;_0---- ----Foundati� n_____.` �?`y_------_: --Property Line------_--------------------------- :. b -51 SEEPAGE PIT [ ] Depth___�_..__---Diameter._. _ Number..___-- ------ [ Rock Filled Yes �— No ❑ Water Table Depth---=------ — -------------•------------- ---Rock Size- - z - - L------------- I f p /� ] Distance to nearest; Well.... 0---__------------_- " -Foundation_-<560---------------Prop. Line_��__ _.__...__,__. REPAIR/ADDITION (Prev. Sanitation Permit;#----------------------wr_-__ _>.___ .__ _t_'` -Date.___ . .:_,_._._ Septic Tank (Specify Requirements] �I-- --- ------------------------------------- --------------- -- •. ; 1 ' --------------------- = p= Disposal Field [Specify Requirements]----- ----------------- ----- -- ---- ----- ----------------------------- -- )-------------- i.__ --------------------------------------- ---- - -------------- --------------- ------------------ ------ -- ----- - - 11 ---------- �; �* I -- tlP 'r k (Draw exis fh11 Lo and'required addition on reverse side] i! [ I hereby certify,that 1 have prepared this'application/ and tha4 the)work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and:Regulations of thekSan 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 sub' Workman's pensation la of California. Signed : , -, ,_ -- -------OwnerBy - -- -- ------------------------------------------------tTitle-------'----------- ------ '-------=-----It (If:-other than owner) i F R DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY--- ., DATE:A:__3� 7� DIVISION OF LAND NUMBER. ]; - a� .,, -- ----- DATE'l .- ------- --------•- ------ ------------------------- ADDITEONAL COMMEN,Y�d `'`�_- - `------- �' -- ------- -------- ----- - " = - r C - C. -- 8' I ---------------------------------------`-----_------- ---- -------- ------ '---------.-----------------------_._' ------------------___......----------------R j-.--- _--- ----------.-._---.------ I i. L,f'',,--- - - ' ----------------------•------------------------- --- - -------- ------------- ----------------`--------."_------- -------------- --`--- ------------ ------ --------------------- Final, ------ - ----------- Final Inspection b /+--f" _ i L _ Date -------------------------------- P Y moo`. - --------------- ----------- -------------- EH 13 24 Iy SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV, 7/76 3M �I