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f FOR Oi=F10E USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT !id ------------------------------------------ -------------- (Complete in Triplicate) ------- No.. '.- 3--- '-----------------=----- ----------------------- ----- -- .3 Date issued.._.5�"'= r',vs"` I, -----------------------r- - -_ _ This Permit Expires 1 Year From Date Issued ---------------- ci 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: ��.. ._, - :...� - ...._.... � _.�, -•- r'�:--r-- -•ter-. ;:JOB ADDRESS/LOCATION.: -XF-//----- ' -----------l�Iy-----------------------------------------------------'-----------CENSUS TRACT.----------- -------------- Owner's Name..--- -- - -------- ---_-.-- _ : . Phone �:. --- Address - �f~ -- ---- --------------------.---- -------City--- 'z''`------------------ --------Zi P 4 e # . �.:�, E -- ---------------Phone----------------------- Contractor's Name Installation will serve: r Residence �' Apartment House.❑ Commercial ❑ Trailer Court ❑ 1 I ❑ Other__ Number of living: units:- -_. _._.__ Number of bedrooms`______.__Garba a Grinder-_ .___ Y. ( . Mote --------------------------- � =Lot.Size---=---------------- '--------=--=--•--�----' { - Water Supply: Public System and'name-- - - - --------.- --.------.-------- ---�-- _-: ------------ ----- ------ .------------ - - --------- ---- -Private,[' Character of soil to a depth of 3 feet: Sand ElSilt ElClay ❑ '• Peat I❑ Sandy Loam Clay Loam ❑ , i Hardpan b Adobe ❑ , Filf Material._.._-__._-If yes,type__________________ _ _—----T. ' (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 #eet,) PACKAGE TREATMENT [ SEPTIC TANK :[-] "� , T Siie__ -_- --' : -'" - }"-' -----------------------Liquid Depth._-----____-- {/y I I r ".r Capacity.--- _ =- Type ,__ r�Material No. Compartments._-_-- „ •--�--s•-• r-a .. 9 _Distance to.nearest: Well...___. � _ : -:_____Foundation 4:� f - _____ - Prop. Line ;- _.______ - '�^ 4 P LINE [ ] No. of Lines-:------------------_________Lengtlftof each lin& !_.,__ -------------- D ) - ::.._Total Length ------------------------ ---------------- LEACHINGn ` i _ 11` YP --- - epth Filter Material,,.-= ------------------------------------,, -----------------.-- -- 1 D' Box_.._._ -` _T e Filter Material-}._•.--.-� Fou D y ------F_- - _ -------------- --- . + Distanc&to nearest. Well __ dation' _____ __ _ __Property Line______ ___._ - . --____._.____ fi .: a ...:,_ `C` .. ',.••_,. - .._. � �... ..-i...-.-� -.>-..5.�, ...L, .e��- ._. " SEEPAGE PIT [ ] Depth----------------Diameter- -----:----- ----Number_--_]------------------- ---.`_ Rock Filled Yes ❑ No ❑ i Water Ta"ble:De'pth--- - Ze Rock St Distance to iiearest:Well-;----- = 3 ounda'tion------------------------- Prop. Line--------------- -------- ( 1 REPAIR/ADDITION (Prev.-Sanitation Permit#-- --------=---'=-:-- '-"----------- ---=------- to^ "- -----, -----------) Se tic Tank (Specify Re uirements -------------------- ----- P ( P Y q ) ---- ------------ ------------ -- ---- ----�-------= ---- --- --- -- --- / -: --------------------------------- ,j Disposal Field {Specify Requirements)_-dCc_.6�.�'�-__�� -----------�--- ' - X � -. ,, -`- -- ---------- ----------------- - ` (Draw existing and=req aired:addition on rev&se side) r I( I hereby certify that I have prepared •this application •and"drat the "work will be done in accordance with San Joaquin County d Ordinances, State Laws, and Rules:and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: 1 ; '3 "I certify that in the performance of the woik for'ihich this permit is issued, I shall not employ any person in such manner as._ l to become .subject to Workman's Compensation. laws.of California.':._ . - iSigned---------------=--- = - ' -------'-----------_-....-�� r��---- --- ---.-.. --�nar Is BY( s Title. "c -w a (lf other than owner) t S FOR DEPARTMENT'USE ONLY x ' APPLICATION ACCEPTED BY_' . . ----------- = � - --'� DATE . DIVISION OF LAND NUMBER_ - ----- ------------- DATE a. ' -- - ADDITIONAL COMMENTS------------------- _- ----------- ------ f tl ---- -- - ----------'---------------------------- -------------------------------------- ----------. ..------- -- ----- ------------ - ------------------ ----------- -------- i - . Final•Ins Inspection b "� P Y Date.. ---- ----- - EH 13 24 SA JO,,QU1N LOC . HE LTW61STRICT F&S 21677 REV. 7/76 3M R �P .