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FOR OFFICE USE: .y FOR-OFFICE USE: - l APPLICATION FOR SANITATION PERMIT ------------------- - ------------- --------'--- �. Permit No.73?----/:5� (Complete 1n Triplicate) -Date Issued.ct�._-:�r�'-�9 ..................... .. _. ........ This Permit Expire.1 1 Year From Date Issued 1 Application is hereby made to.the San Joaquin Local-Health yDistrict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinan& No. 549 and existing Rules a Regu tions: JOB ADDRESS/LOCATION.._.. .. .....'�I ... SUS TRACT................ Owner's Name. . ---------- ••----- -----------------.--Phone -------- ............... ......... U Address_..- .. - � - ----- ... --- - ------ --- -- --------- ---" --- City----------- -----p-------- Zip} 44 a- Contractor's Name._-.--- .. License #. (r. �- -. .Phone..` _ ` . . Installation will serve: Residence ❑ Apartment Ouse ❑ Commercial ❑ Trailer Court ❑ i, Motel E] Other. ......_... i _ _ m Number of living units:______ __ ___ _Nuber of bedroom 11 arbag�rindw ...___.-._Lot Size__._-_�.-�U-'/1 l 0-Le,..... .. .. [ Water Supply: Public System and name.. .............. . Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Cllo�y ❑ - Peat ❑ Sandy Loam El Clay Loam 171I Hardpan ❑ Adobe ❑ Fill Mate aI If yes,'type............ ................ . I (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 perILitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( •] SEPTIC TANK [ Size .j x... . - 1_� -----------1.Liquid Depth.__. ._------- lt�4 Capacity-./.- '...0_Type... �I Material. --.•---..-.No. Compartments_...__ — ---------------� Distance to nearest: Well...-•- _ J� Foundation_..__�� _....... ...Prop. Line_._..._.:_.....__.__... 0-I� .. ... LEACHING LINE [ No. of Lines _ 51v..----.........Length of each line '._. __ ------Total Length .. 'D' Box. T e-Filter Material_.._.... Depth Filter Material...._..-_. .. p p A Distance t�st: Well__.. alt �!...._... oundation---------------------------Property Line '�----.------- ---------....---., n � SEEPAGE PIT ' ` �...Diarrseter..___._ _._ I Number.._._.. _. _ _ Rock Filled Yes No ❑ ( 3 Depth..- c/.._. Water Table Depth.-----...-- '------------.... . ........--- - -----------Rock-Size.-... �j � ---------•---------- - Distance to nearest: Well-................... ........... -------Foundation._.,-----------...- - -- Prop. Line_ ---------- ---------- REPAiR/ADDITION (Prey. Sanitation Permit#---------- ':'-'. _.. ......_._.Date._..___..:_.......-.--..--.-.--.--.-_--.------) �ISeptic Tank (Specify Requirementsl.......... ... . ----------------- .............. Disposal Field (specify Requirements) ------------ ----- ----- - ------x_. - ' ' ---- ------ - ------ ------------------------------ (Draw existing and re4"uired addition on reverse side) I hereby certify that I have prepared this application and thIll't 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 "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as i. to become subject to Workm'on's Co ensation laws of ?California." Signed.---- ..: :. ' ....:.. Il'-- - ----Owner BY = - -' .- _.... Title . --'-- ---- . ............... ---- ------- (]f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...... --------------- -- -----------------------------------DATE ....... - ......---- DIVISION OF LAND NUMBER. ,J ..--' . ----.. . .. --_----- .......-'--'- DATE -.. . ' " ` ----°---.._... ADDITIONAL COMMENTS -. - -?--' ---- -'� - �� ....... -- ...................... ......... . =I� ---- ........ --- .... ....-'--_. _...---•-------------------------' -- -'-'------- • ----------------------------------------- --- ---- ------------- '` ... ----._....---------------------------- ------ . ---- .._..-.-- Date._ - Final Inspection by:... �� ... - ,tet--�._. . �-- - - -- - --- - - - ---- - -------- EH 13 24 SAN-7OAQUIN�LOCAL HEALTH DISTRICT F85 21b77 REV. 7/7G 3M