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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y� (Complete in.Triplicate) � Permit No----------------------- 1 i --------------------------------------------------------- —)",A �� E ,ti �� Date Issued-- :3/' 7fl This Permit Expires 1 Year From 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/LOCA ION_._; . _ -� _ :- - • 2 �,� , / _ -- - ---�- ---- - �- -- - - - - - ----.•..---- �� .CENSUS TRACT---------------- Owner's --- ----.. •- ------ Owner's Name- -- P - --- --------- - ----- hone ----- k Address-----= • /�/l r city' t . Zip Contractor's Name_._ _9 _° --- ,fff/Y. _ �_Z• -------_- #-•3a` .7�. _Phone �'��= � � r 1 License [ Installation will serve: Residence ®l partment House.❑ Commercial ❑ :Trailer Court ❑ r Motel E Other-------- -------- - ------------= - ---- Number of living units_____________ Nui-hber of be'droorns�_.__-Garbage Grinder----_____-_-._Lot Size______ __. i9;*ees--------------- Water ---- _---,-Water Supply: Public System'and name----,---------_---- ---------- ----------------- -------- -'-- -------•-- - --- Private Character of soil to a depth of 3 feet: Sand ❑ ,Silt❑ Clay ❑ Peat ❑ Sandy Loam K,___�Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material._.__.------If yes, type------------_--__________.__.__ (Plot pian, showing size of lot, location of system in relation to.wells, buildings,'etc.'must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,)' PACKAGE TREATMENT [ ] SEPTIC-TANK [ ] Size----- -------------------------------------------- ------------Liquid 'Depth.-------.--_------ Ca'acit - -- ------Material----------=---- ----------'No. Compartments-----------------------=------ - Distance to nearest: Well----:,_:;._:---=------------------------------Foundation-----------------------------Prop. Line------------------------�--_ LEA i INE:,, [ ] No, of Lines--------- Length of each line.- :-::----------------- N; ----Total Length.:-.---------- --------------- ------ ; 14 a D' Box_ __.._Type Filter Material._.___,.__________Depth Filter Material________________________ ----------------- ----------------;- } Distance to nearest. Wel!-------- __ ______--Foundation-----------------------------Property Line--------- a SEEPAGE PIT [ ] Depth-__---- __--�'i__Diameter ------------Number__________ _____'_____ ____ i Rock Filled Yes ❑ No ❑ Water Table Depth.--T---------- -=------------- ------------------Rock Size' = - Di`stante'to nearest: Well. ------------------ --=------Foundation- Prop. Line = REPAIR/ADDITIONPrev:-Sanitation Permit. `'----------------------------Date---------_- Septic Tank'(Specify Requirements)----------L ;--- - --- ----- = -------------- --------- ---- ----------- Disposal Field (Specify Requ aents]__._____l �- L/ G''--_-- --- -- GLIhCJ-------•-s .'---1.4 --?-q�{�---- - _ moo ' 0 )A--- -------- *l [ -------------------------------------------------------------- -------------------------;.-. g ' d required addition'-on reverses`r (Draw existin '' a�, � q i ' 'dditi I hereby certify that I have prepared this application and'that.the work-•rwwill_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 ature certifies the following: F f "I certify that in the performance of the work for which this permit issued;I' shall'not employ any person in such manner as to become subject to-Workman's Compensation .laws.of California."\,. .. _ A. Signed- -- -------- ----- -- --------- --Owner _ - ------- ----- SY -- - - - - -Titl - �- ,r-_- (If _ other than owner) FOR-DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY------ -------------t---- ---L`•- _ - ---- ---- ------------- DATE._.�r.`J 4_c_7_ - - ------------- ---- - DIVISION OF LAND NUMBER --- -- -- " `DAE�"N.� ------3 ADDITIONAL COMMENTS. = - ------------------------------- ------------------------------------------ --------- f � -;-------= ------------------------------- -- .-. 1. , .. , ----------- --- ----------------- ------------------- ----------------------------- --------------_---------------------_-------------------- --------- ________--___ _ __ J t f ------------=---------------------------=- --------------- -- -- --------------------------------------- Final,Inspection =._------------------------------------------ r f= Date ' '� 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76'3M — "" _