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FOR OFFICE USE: I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No-___.____'----------- ------------------------------------ -- �--- 111 -7� Date lssuecl__/._ _____________ ---------------------- - � - This Permit Expires 1 Year From Date Issued _ "J\ �! y . 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATIO . _ o��f __ ., _ _`_.._____. -Jc .__.CENSUS TRACT.---------___.--.___.__---___. Owner's Name............... ' - n �} +� '" -��-9------------------------------------- ---- ---------------------Phone--�46.'Q7_l/ . Address f^ C--R, ---_---City- --- -------- --- ----.- ----------- zip--- -- -- --- ----------- - ' �C�Contractor's Name------------- ----License ----Phone'.(/A---- rte--- ------------- Installation --- ---- Installation will serve: Residence �( Apartment House.❑ Commercial ❑ .Trailer Court ❑ a Motel ❑ Other- `---------------------- -r-----------=--- Number.of living un.its:__a.__;_____Number of.bedroorns_--.!__.....-Garbage Grinder-------------Lot Size---- ------ - ---------------- Water Supply: Public System and name -- ---------- --------------------------------- =----------------------------- ------------------ Private Character of soil to a depth of 3 feet: Sand Silt Clay _ Peat Sand Loam Clay Loam p ❑ ❑ Y ❑ ❑ Y ❑ Y ❑ Hardpan Adobe Fill Material__ ------If yes, type__________________ ----------------- --- r (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: `(No 'sepfic tank or seepage pit permitted if public sewer is available within 200 feet,) I PACKAGE TREATMENT ( ] SEPTIC TANK p� " Si e-----.__.__-..;...x-,c` -- Liquid Depth,-,15 -------•- ---� Copacity-t'kOP-_' %-__sType ---- ------------ `.__Material__t ?� -___No. Compartments--'-----------t_____ ,________--- t Distance.to nearest: Well_-------A� �'------- ------------Foundation-------/_d-�_-_______Prop. Line-:S----------- LEACHING --- _LEACHING LINE. [ Q No. of Lines--- --- ----'Length of each line.----- .r'-------------Total Length.-- y------------ ----- D' Box Type Filter Material.J�{Jr. -_____De Depth Filter Material__- -- YP P l-- "�l : Distance to nearest: Wel1____.1: ____._____.Foundati n_.____�. :_ ` -___.__Property Line _______________ SEEPAGE PIT Depth_ Diameter,___ 3___.----Number--'----_ __--_-_____________ ` T Rock Filled Yes No ❑ ! R� Water Table Depth---:--------- Rock Size_ ------------ c R Distance to nearest: Well _ �`� -_ - o.undation Prop, Line_ �•S_____._ _ ____ ear^ t . c i - N 'PAIR/ DDITION (Prey:5arfitation Permit#_:_`__ ____________________________ ______ Da#e------------------------------------------ ) Septic Tank(Specify=Requiremerif l'-- ." ------------------------- ------------- ---------= -=----------------------------- ---- - Disposai'Field (Specify.Requirements) -- --------------------- „--------------=--------------------- --------- - - a _ .. _ .. -------------------------------------- ---- ------------------------------------------------------------- ---- - ----------------------------------------------------------- ------------ ------ - ----- ---------------------------------------------------- r (Draw existing and required addition on reverse side) , I hereby certify that I have prepared ibis 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: z "I certify that in the performbrice 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." # Signed ---- - �- -Owner r _ 'By. - _ ----.Title--------- -- ------------ ----- ----. her'-thanownerj - . . . , ii FOR'DEPARTMENT USE ONLYi APPLICATION ACCEPTED BY { - ,. ;' r=�'` DATE. _ ----- -- -__ 4 .� DIVISION OF LAND NUMBER-------- I DATE - ADDITIONAL COMMENTS----------------- ------------------------------------------------=------ 1 . -'--- ---------------------------------------- ---_-------- ------------=--------------------------'-'------------------------------------------------------------- E -----'----------------------------- --- ------ --:- - - - - - - ------------------- ----------------------------------- Final Inspection-by:- = '_- " " Date: 7� J ---r f------- EFI 13 24 SAN JO QUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M!