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f � FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ ' Permit No.,;�B'__il.6-7- - - (Complete in Triplicate) ----------------------- --------------------------- - i� R -«-., Date�lssued.8'_—f.28' ---------------------------------------------------.._.__ 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: a JOB ADDRESS/ TION / I� - CENSUS TRACT---------------------------- LOCA� Owner's Name. C•-l_-- ,- 3 _ -= -----Phone-------------------------------------- �j/ Address �_//�_ - - --- ----------------- -------- - City j&4_44;i ZiP r-. ' License #-G3 Phone__:�4. ?�� Contractor's Name- O ------------ Installation will serve: : Residence Apartment House.[] Commercial ❑ Trailer Court ❑ i x;_.. ��..;- - Motel�❑ �Other_.:-----==---------------=-----°----------- _Garbage Grinder -_�_- Lot- = =___ — _�- ----- I Number of living.units:__'___ Number of kiedrooms.... = ��- �� ' -- F ---�- ---- Private[❑ Water Supply: Public System and name--_-__-.-: --------- ---------- - '- Character of soil to a depth of,3-feet: Sand ❑ Silt ❑ -Clay ❑ Peat L� Sandy Loam ❑ Clay Loam ❑ �Hardpgn ❑t 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: (Noy septic tank 'or seepage pit permitted if public sewer is available within 200 feet,} i PACKAGE TREATMENT"[ l" ` SEPTIC TANK [ .} . . Size------------------- --------------------------------------Liquid Depth--- --#--- a t _ # _No Compartments--=------i= --- ------ capacity------- ------= Type Y _ .. Distdnce,to nearest. Well- ---- -- ------- - _ --------Foundation------------- ---- ----------- Prop. -Li [ LEACHING LINE [ ] No, of Lines-------------------------- lin, 5.--.of each lin .-=---------------------------Total Length.------------ --------------- ---. ------ - - D' Box--°------:._Type Filter Material__----_------_.....Depth Filter Material--------------------______ ------------------------ i Dista nearest: Well---------------------:-----Foundation----------_-------_-------.Property Line------------------------_------! f SEEPAGE PIT [ ] Depth....r- ----Diameter=------ -------1._Number___'------_------------------ _-- ` Rock Filled Yes E] No❑ i Water Table Depth---------------- T-------#-------- --=------------ ---.Rock ;Size-.--------------------------:------------;------ Distance-to nearest: Well-"' ----=---.--Foundation------------------ -------Prop. Line_.------------------ # _ ---------- REPAIR/ADDITION {Prey: Sanitation Permit#-.=___. .___-'w------ --'--TDate_________________________.___.__----___ ) Septic Tank (Specify Requirements)--- --=------ ---- ------ - --------------------------------- --------------------------------------- ------------ -- ------------------ I r - =Disposal Field (Specify Requirements _____________ _ ---- --- - ----- - ------- -- -- -:-- --- --- - :. --k F -------------------------------------- �- ------------------ {Draw existing 'n required addition.on reverse side �- �_ hereby certify that' have prepared this application and that the work will be done in accordance kwith Sari 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 perrtiit is issued, I shall not employ any person in such manner as to becorn iec to manCompensation laws .of California." 4 i _ �. -----=-------Owner r f Signed- - ----------- - - By6044 =•-------- --- ---- Title--- <: `�"'�_-----.-- ----- -- --. si (If other than.owner) . t i � R� EPARTME T USE LY l APPLICATION ACCEPTED'BY ." _ 1/j,� T `' DATE------- _' - - - --------- ---------------� ----- -- - ---- -------- ------ ------------ - - DIVISION OF LAND NUMBER..-- .------ DATE <------------------- - - ADDITIONAL COMMENTS---------- - - - -------------------- - -- ------------------------------- ------ '.�,1.._ o 1 - -----------------=-------- --------- -------- ------------- --------- ------------------------- - - - - - �' S-:;-- -9----------------------- Final Inspection-by.-.- � --��__�- - - - - --- --- -------- ---Date ------ ----- - f ` EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M-