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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Tripllcate) Permit No._ - -------- -------- --------------------------------------------------------- "^" �'"~ -----This-Permitfxpires 1'Year From Date Issued ' - Date Issued__�. 1��7 Application is hereby made to the San Joaquin LoclaT Health Distr4'ict 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: _/ n JOB ADDRESS/LOCATION..__L_/+�6,�___ fJ-J�j_ -p _ -------------- --- ----------------CENSUS TRACT --- Owner's�Name------------ ------- C..K. � �Sa7. �; - -----:-- ----Phone__ �� / ' Address =- - r f?'7 €3 s'+ ©e�TO City_ --------------Zip Contractor's Name...____-.. _ ------ ,-. -.AI `T�._License #_2a��...7" �__--Phone___ w� � p __ t R.�_► _f/__�t Installation will serve: Residence' Apartment Hots e.0 Comme tial ❑ Trailer Court ❑ JJ Motel * . _ _ - m -------------- --=--- u u ----- ro_;-m-` s---�Gar=bi ajge Grinder-Numbero . ...__.._ ti Lot,Size__. Z r ,---------------------- y: Public Systern,and name---- ,-----_-Water PPaI ---------------.---------=----- -------- I --------------Private Character of soil to a depth of 3 feet: Sand Silt Cla Hardpan Adob, Fill aterial - P lft❑A..$andy Loam'❑ Clay Loam � P ❑ yestyPe------------ (Plot plan, showing size of lot, lo cation-of in rel' wells, buildings etc. must be placed on reverse side.) NEW INSTALLATION w(ho septic tdnnkJor seepage pit permitted if public sewer is available.within 200 feet,) PACKAGE ENT? ' P I I ] SEPTIO,TANK:I=7 Size_t_- --------=`t # (A TREATM .z ' Capacity - '"�"__T e.::'.'�'• - r� '� - � ---- -----�-----� -Liquid Depth---------- ----------- ( -----Distance to nearest:.Well` Mater,ial.._------ - -------------No. Compartments---------------------------------- QO Ca aci �-- ------ yp -- ----k- i------Foundation---------------- ------ Prop. Line-:------------------------ . _____.Len th of each line._ LEACHING LINE [ ] No, of Lines- ,_-- g :. :_.Total Length..-___...__ D-11-Box _ -----Type Filter Material_. .-----------Depth Fitt r Mater.ial.._. I _ - ---- ---- t rDistanceto nearest: Well_--------------- Foundation:'�tiA-..______-------------'_. .Property Line, .____-- SEEPAGE,PIT f[ l - <pth---- ----------- ameer.------- -----Number. t. Rock FilletYes E] No ❑ { Water Table Depth.-------------------- -------=------ 4: ' - = Rock Size--------- !Distance- to.nearest: Well---------Z_ ------Foundation----------=------- Prop. Line - „Y f t REPAIR/ADDITION {Prev. Sanitation'Permit,#------,.. ---------------------------------------Date-----------------__-:._.:_________ Septic Tank (Specify Requirements)_____. X - o , = --------- ------ ; - ..,,._- � , ��► .� -r .C�Displ Feld (Spcify Requirements)..- _- -- 7-- ---------- -------------- -- --------`tea--�---- --- 9 ------------------------ (Draw existing and required addition on reverse side M. I hereby certify that l have prepared this application and that-the work will be done in accordance 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 theperformce of the work for which1 this permit is issued, I.shall not employ any person in such manner as to become subject.to Workman's Compensation laws of California." g ' - S� ned -- - -----------------.--------;---------------------- ------------------- nCrwer h s. S � '-----------------------� ------ ------Title----- --- --------------------------------------------- -- --------------- - , �--- (If other than owner) - � ,�• FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ _. DATE..-/_-----��`-�7 ------------------- DIVISION OF LAND NUMBER-:•---- --------- ------------------------------------- -- ---:_ --------------------------------------.:DATE ADDITIONALCOMMENTS--------------- --------- ------ ----------------------------=---------------------------------- i ------------------------------------------------ -------------------------------------------'--....._--------------.....'------------------------------" - - F -- ------------------------------- ------___..-..- . - ..._ -_ ----- -_ ------------------ - ------- rf Inspection by _,Zrnf -------Date -------------------- -- ------------------------ SAN ------ ----SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3m '^!_1 me