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FOR OFFICE USE: l APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit Na/.tl.. .;�.- ............ <: This Permit Expires 1 Year From Date Issued Date Issued .....r�.�...Ic Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. j This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION..-.-..- }lel.-tt..2 r .S._) 0C_hC�D" .........CENSUS TRACT. Owner's Name _...... _. +�. . . - if S. // t --------- --------- -.Phone.. A.6_s Address---------- ------- Cit yyS J .� Contractor's Name._...... _.!r1r.Z1/L(5..4 ./-tvD 2Sy �a�f i - -License # _Phone s�.�.9 cQ_- I° Installation will serve; Residence t Apartment House ❑ Commercial ❑ Trailer Court ❑ ,,; Motel ❑ Other --------------------- Number . -Number of living units:..... .........Number of edrooms...Z- ..Garbage Grinder.....-------Lot Size..---- Ox.r a.0 � Water Supply: Public System and name.. .. _. ... -- - ----------------------- ,.. .:. ; : •--Private Character of soil;to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ `" r` Hardpan- p ❑ `Adobe Fill Material.. .. ....lf 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[ ] . . SEPTIC TANK [ ] '� Size.._ .... --. __.Liquid Depth---------------- Capacity...... .. -----------TyPe----- ... ..........Capacity...... ..j.....-----TYPe----- y---- ...Material--------------------------No. Compartments ------------ Distance to nearest: Well- ---------- ...... ........... .Foundation...: --. -... . . .... ........Prop. Line _.-.-........--...... LEACHING LINE [ ] No. of Lines - -------- - ----- -----Length of each lina----------_-.. ........._. Total Length .. ----------1 'D' Box_ .:.:......type Filter Material.............. .....Depth Filter Material ............ ------- --------- ---- ---- I Distance to nearest: Well----------------. Foundation-----------------------.--.-Property Line.............. .._-........ SEEPAGE PIT [ ] Depth.,__ __6ameter...--------•---.-- Number-...----------------4.._....i.. Rock Filled Yes ❑ No ❑ _ Water Table Depth.................. Rock ISize.-.....-......... - .....- ----- Distance to nearest: Well• - ........ -------------Foundation--........... -.Prop. Line-- ...--------------------- ------- - --- -- REPAIR/AdDITION [Prev. Sanitation Permit#-:....... rG y Date------- Septic �� -- -----1 Septic Tank (Specify Requirements)- O_ .. �il e...-.,cu-S T--. 7-4ajk -fit►- : .-:rL��. .- f'�a ----------- Disposal ------- Dis osal Field (Specify Requirements)...- ------------------- .......... e uirements1 ---------. ' - -- # - ---- ----------------- ...... .......... ... ..... ----- ------------•------------ ....... (D raw existing and required addition on reverse side), I hereby certify that I have prepared this application and that the work will be done in 6ccordance 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 th work for which this permit is issued, I shall not employ an person in such manner as to become subject to Workman's Compensation laws of California." p y y Signed. ...._ ....... Owner BY -r: -C.ccct D.... -- ....Title. 7`!. l (If other than owner) FOR EPARONLY APPLICATION ACCEPTED BY....... ...... ..r..-_ ..... ....... --•--....... DATE -----... .. DIVISION OF LAND NUMBER. �.- _;'.... ..- _.DATE ADDITIONAL COMMENTS.. ........... A ........................ ..... ................ ._> ----.... ---------- --- ............ .. f ! t p� - . t .. ... $ _ ... --- . ............ --------------- ----- % ina Inspection by:. - -- ------ ----------- -------------Date...--. ... �- . . ....................... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M