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aI FOR OFFICE USE: i FOR OFFICE USE. L, :PPLICATION FOR SANITATION PERMIT ----- ------------ -- -- --- ------------ --- � Permit No.- �� -•� 3 �- ."(Cannplete icl Triplicate) ------------- --- ------------------------- ;.) Date Issued.-,-,_- ---. - -__------------- This Permit Expires 1 Year From Date Issued # : Application is hereby made to the San Joaquin Local Health District for a permit g4., stl�ct a s 1 L work herein described. This application is made in compliance with County Ordinance No. 549 and exisfnelnc�Ru�tils: pp ._. JOB ADDRESS/LO -------------- &.-R1 - - - ---U� �L�/ f ------------------CENSUS TRACT.. �osSc------- �} :.�. ------ ----- -------------------- --- ----Phone._,3 Owner s Name _. _ . � cc Ad'dress---a:.?- �--- ----------- ------------------------------------------------------ ---City-- -------------------- ------------------Zip------------------------------ -POSContractor's Name-- ---- j�G-- -cJ '__------License #_ 7�i�----Phone---c --.- -33' . lnsiallation-will serve: Residence ❑ Apartment House Commercial— railer Court ❑ Motel-•❑ Other—_ ----- Number of living units:------.---.__.Nurnber.of b'edrooms.------_.--_Garbage Grinder----..----_-Lot Size-------------------------------_-----_--- . ----------.-. Water Supply: Public System and name ------------- ------.---------Private,.o i Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ Clay Loamg�-- Hardpan ❑ : Adob4,❑ Fill Material-----.------If yes,-"y ----- -------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,`etc.,imust,be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep ge.pit permitted if public sewer is avails le within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Size-------5-/t':------ ---------------------' ---Liquid Depth_ -_------- --- Capacity/otbO-g,O.•Type.-- '-------Material-.afv--;:_..--_-_No: Compartments------.21----------- ----- D C) Distance to nearest: Well l _.-__.__ _______.:Foundation ..___------------------Prop. Line __ LEACHING LINE [A+---N , of Lines-.... ..._......-:Length-of otK line---:�v----% _-..- .Total Length.--------------------------------------- "D' ..----------- --_---_ -_"D' Box..^h_Type Filter Material / �/-'Depth Filter.Material- . ..�-r- ----------- - ------ ------ 1 " �/fir Distance to nearest: Well_^-------------------- Fc uhdation------- ------------------Property Line----------Q -------------_---" SEEPAGE PIT Wl Depth.�-s�_ � ---_2 = Rock Filled Yes.�No.❑ Diameter l' Water Table Depth----- - .. _Rock':Size--/-------------------------------- -- /L - - Distance to nearest: Well__ j_ .r" ------Found ati,on.--� _.Prop. Line..__ _�..- r i. REPAIR/ADDITION (Prev.,SanitationPermit#--=------=--------------•-------- --------------:Date.-----,-----'---------------..__---------------- } ti. . Septic Tank (Specify Requirements) ---------------r---------------�~--=------------------- --'--------- ------------------------------------------------------ Disposal Field (Specify R.equirements)---------------------...... , Y � - `z 2-------- ---- ----- -- -------------------------------- ------------------- -------- - ------ - •- ' i --__ - ------------. - _ ------------------------- ----------- -_.--__-_ _- - ------ --.-.---.-_- --- ----- .. --- ------ --- --------------- ------------- - -- -- -----------------------------------------'- -------- (Draiexisting and required addition on reverse side) I hereby certify that ha.."ve prepared this-application and that,the work will be. done in accordance-with San Joaquin County Ordinances, State Laws; and Rules and i gulations of.the; San Joaquin Local Health D�FtrIct. 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 sh "noi employ any person in such manner,as r to become subject to.—Workman's Compensation laws of California." A! Signed _. = - ----------------------------------- r -. % ner BYJ s - `L Title (If o#fier thZb)h:owner) ` FOR DEPARTMENT U• ONLY PPLICATION ACCEPTED BY -=--- ------------------------------------------ DATE -.- ------------------------ -------------------------'--_DATE DIVEISION OF LAND NUMBER.------ - ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------- ---------------------------------- - --- --------------- ------- ------------- -- ---- --------------.----------------------.---- - --- -- y --- --- ---- ---- - - - --- i Final Inspection by: - Date::. - -r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV, 7/76 3M