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) FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit -•-••----------------- --------------------------------- This Permit Expires 1 Year From Date Issued Date issued_ .!n5-7)._!_- 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 incompliance with County Ordinance No, 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT ION------ :-S_-� 7 i efl _.CT_ GENS S TRACT------------ Owner's Name.'. __.Phone -!�3_(R-,?%3(o Address.--- c3.ytn City ]�7-a�. -.---- __ ------Zip- ---- - .. _ Contractor's Name-------------- ?� --- 1 ---------- -=-------- -----License #--_--------- -----°---------Phone Installation will sarve: Residence E]- Apartment House.❑ Commercial ❑ 'Trailer Court. ❑ �.. Motel ❑ Other---- Nu I mber ther----Number of living units:---------------- Number.of bedrooms______-'---Garbage Grinder_-----------Lot;Size_______________________ Water Supply: Public System_and name------ ------------------I-__-__ .x ----- .- ---Private ❑ - Character of soil to a depth of 3 feet: Sand E] 'Silt❑ Clay E] Peat E] Sandy_Loam.-0 : .Glay-Loam HardanFill-Mat" ❑ ) ❑ Adobe. _.. Fill-Ma ter al ..... If yes, type------- ----------------- { t _.n (Plot plan,-!�howing size of lot, location of system in relation to:wells, buildings, etc._must be placed on reverse side.) 141 41 NEW INSTALLATION:' (No' septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ]..._. Size - '- - t. f --------------------- --------------Liquid Depth--------- ----- ------ --- Capacity ---- i o.--Compartments -=------ ------- " l�:a ---- - -N Distdnce to nearest: Ue1l =" � - - ------=-`------Foundation:------:__-_,.-----• Prop. Line ------=-°------- ---- cn LEACHING LINE [j iN_o.. ofLi_n._es.' ._ .. [;. To_ta_ l Length.-.--,,,th-- - - D' Box_ _ -Type Filter Material a _______ ____ _____Depth Filter Materia ------ '--------------------------------- Distance to nearest: Well----------------------------Foundation----------------------------.Property Line----------------------- SEEPAGE PIT [ ] Depth-----------_----Diameter__------- ------------Number___:_.____ _--- Rock Filled : Yes ❑ No ❑ �w•car. - ab a Depth--- W " ,--.Rock -------------- - ------�Ty ' ater T Ir - l i � -------- --------- --Foundation- ----=----------------Prop. Line----=-=----- 4" Disfance:to nearest: Well_,____ _ ____ REPAIR/ADDITION-{Prev:Sanitation-Permit#_'_' _ __________ ' f - - - Date -` Septic Tank (Specify Requirements}.______._,."-------------- ------------------------ IS posal Field (Specify Requirements) _ �!: j c � " - - _____ _ ---------- __ . ___.___-. .___t_________________________________ - '9 - -_ - --_ __ .____--_ _____ __ _ ____ -..___ _ _-- ______________________________________._____..__._____....__-___._ r = ----------------------------- - I i (D haw existing_ad required addition on reverse side) I hereby certify that I have;-prepared this`app!ication 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: f "1 certify that in the performanie of the work for"which this permit !s' issued, I shall not employ any person in such manner as to becomes j Wo mans .Compensation_laws of California." .- Signed/-_-- - By- wear - ---------- Tit- _ (If other than FOR DEPARTMENT USE ONLY' ; . ..,. .._ ,. APPLICATION ACCEPTED BY -- . --------------------------------- ----------DATE: = DIVISION OF LAND NUMBER -- -= = =_ ----------------------------------------DATE ADDITIONAL COMMENTS-----. .e_ - _ -------------------------------------------------------- ------------------------ ------------------------------------ ----------- ----------•---------------------- --- ---------------------- :_ ------------------------------- - --- � Final°°Inspection by:--- -- ._ Date r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M