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f ,f F FOR OFFICE USE: ✓ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- ----------------- (Complete in Triplicate) Permit No.749--�._ 40 _ ----------------------------------------------- -------- Date Issued_/.,0_:1/._ 8" ---------- ----- -------------------------------_.------- This Pe-n4t Expiresfl Year Frani Date Issued 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: ! JOB ADDRESS/LOCATION -- ------.CENSUS TRACT-------------------------------- Ow ner's -------------------------------Owner's Name.------- - -------------------------------------------- :._-.Phone.-- ---- ---- -- Address. - ------- -- ------ --------- City --------Zip------------------------------ . ... t r ---*- Contractor's Name---- �- - ---n--- -- --- -License #--- `2Phone-----------------------------'---- Installation will.serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court L] t I g Motel ❑ Other---------------------------=----------------=- I Number of livin units:-_,__l--____ Number,of bedrooms__ _.Gar.bage.Grinder_._________.LottSize.__.._3_�,2��. __________ ___ Water Supply: Public System and-name.- ------ -----------=------- :. ---------------------------------.------------- -L--- --------------------- ----Private Character of soil to a depth of 3 feet. i Sdnd ❑ 'Silt❑ Clay❑ Peat❑ Sandy Loam Clay Loam ❑ p ❑ ', ❑ Hardpan K Adobe. Fill Material--------------If yes, type-------------------------------- (Plot ____.______}___:_ __.__- f t - (Plot plan, showing size of lot, location of system 'n relation to wells, buildings,.etc. must be placed on reverse side.) W + NEW INSTALLATION.' i(No`septic tank or se age pit permitted if public sewer is available within 200 feet,) r PACKAGE TREATMENT [ ] ""SEPTIC TANK [ ] . Size. f ---------------------S/ _ `__b __ - - -----Liquid Depth i.. .. -Capacity.)_:;��P-o-----Type- Compartments_._--aZ ------- --- �../. � -- �--b._.:_______Prop. Line-_-_____`�_/____.f___Distance to nearest; WeIL-__._-__-.-- v-__�____ ____Foundation � F LEACHING LINE [r] No..of Lin es _____________ _---_--.Length of each lins.__-_-.-._7 - Total Length _._._1. �___.__________._.__.___ Ik r D' Box-----/: _Type Filter Material S_ __- D pth Filter Material_. _ ______ _ __ __ ____ __ ___ t Distance to nearest: Well_. -�.--`-.--.Foundation -_ ��r-:_-�- Rwperty Line I" S [ l Depth 1-2—!_-D -- Z- l _Number. Rock Filled Yes o E] a bleDepth.---�------- Water Ta -- } . t ---- 5 . ------- - ----------Rock Size.----�- -�=-• --Xr3-------------------- x Distance to nearest: Well- --- ------__-`_.a.-._ -: Prop- Line._____-_�-_-_-- - - ------------.Foundation- -- --� - - --------- REPAIR/ADDITION (Prev. Sanitation Permit#_-_.------------ ------------------------------..Date--------------------I------------------ .----} $ = —`----- `-----------•----------- t Septic Tank (Specify Requirements)----=-------- _ 3 i. Disposal Field5 ecif Requirements) -------------------- s ------------- ------------ ---------------J__..----� _. - -- 4 _t___- -- .--.f_____---.---___--._--__-.--.-________-. -._--F----------------------------------- .--._ ______.__ _ _ _F__.____________�!ry'___ _ -------------------------------------------------—----------- --- --- - [ - - - ------`--------_---------—--------- ------------ (Draw existing and required_.addition-on reverse.side) `. I hereby certify that'I have prepared,this-application and-thidt-the-work will be-done in accordance with San Joaquin*County Ordinances, State Laws; and Rules. and Regulations of the' Son Joaquin Local Health District. Home owner or licensed agents signature certifies the following: - "I certify that in the performance 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,-6mpensation laws of California." -• ' Signed------- = ------------ ---- -- - - ---------------- --- - Owner . -- . By- -------------------------------------------------- -------_ -- ----- - - le.- � : i< (If other than owner) +� _ +. Tit ....... FOR DEPARTMENT USE ONLY' - --=------=------------------------------------- -- APPLICATION ACCEPTED�BY:`_-__C_ PATE. _ " DIVISION OF LAND NUMBER.---.------------- -----------: :--------------------------- ------------ __...__,...= ..: DATE. ------------------: -------- IADDITIONAL COMMENTS ------------- ----------------------------------------------------------- ---------------- -----------------------------------=---------- --------------- ------ --------------------- ------=------------------ -------- ----------------------- ----------------------------- -----------------_--------- ------------- ------------ ------------ ---------- ---------------------------------- I-Inspection Date d �-�------------------�---- FinabY:-----= ,_ --------------------------------------------•---•-------------------- / EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M