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FOR OFFICE USE: FOR OFFICE USE: �..j PLICATION FOR SANITATION PERMIT Permit No...._ ... - (Complete in Triplicate) - - ----- -_ -........_....... - Date Issued... -.-a ......................................._._----------- 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/LOC70-90-x N .IDIUo.. �l4^/L�ca.4t,_atGt-i}}Lh- ¢�yyf.P.�/W._F�f• _- _- .CENSUS TRACT _. _. Owner's Name.._ 6x.(.p . JIQ(jC1 Gc l2 0 ..._ -- .. .... Phone..! �1-'.�T 9�..Address _ ..... 7 .5—t _ - cityA — --Zip . .. Contractor's Name.... . 4, . 11 License #_...�7 3. 3 Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial 04 Trailer Court ❑ Motel ❑ Other _--..-............ .-------_----------- , Number of living units:_ -------------Number of bedrooms_...._ . Garbage Grinder... --------Lot Size.... . ..-.--:.._..._--- -.. .. Water Supply: Public System and name_ --------- ------ - ...____._,.--- ------_._.Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeNg Fill Material_ ._ ....If yes, type_.__------------------- --- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 0 NEW INSTALLATION: (No septic tank or seepage pit permitted riff public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size... ...J .f rr o - -X-�'�+-�--�-�---�-----------------.._.Liquid Dept��'.---------- Ca acit - YP ^' -- - P P Y-LN1n_.....---T e... .--... _ Mate --..No. Compartments. � t Distance to nearest: Well-------- ... ____-...Foundation..10. . .._.. __. Prop. Line... .. ....____..p LEACHING LINE No. of Linesr SC ----�..---..----- Length �f epoch line ----------- Total Length .. lam.-_.--- -.........__. . 'D' Box- ._L�.Type Filter Material. .__Depth Filter Material...----- - .cr------........_..... .... ___._......... Distance to nearest: Well_-4W---1--_ __..Foundation._ Property Line.... _. ..-__-.-..._..... SEEPAGE PIDepth_.Z .l- -Diameter....� ---Number._.--------------------- RockFilled Yes No Water Table Depth--------.-.---------.----?_..._- - ------------- -Rock Size._ . _ - r Distance to nearest: Well ......_/-....._ -----_----------Foundation.....- 8_.!`. _ ...Prop. Line.,5._...____ .-_... REPAIR/ADDITION (Prev. Sanitation Permit#...... ............................ ...............Date._..... ..... ..__........ .__....._...J Septic Tank (Specify Requirements)-- -- - -- ------ -------------— ..- -- Disposal Field (Specify Requirements) - -- ---_------------- ---- ---- --------- .... - . .. --- ---------------------------- -- -------......... -------- ------- ---------- ------------------.------------- ....... ........... ...................... .. ------ - -- ..... - ---------- ----------............ - ..._... .. -- - ---------I---------- ------------ __ --------------------------------------------- ...... __ ...__..... ...... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application 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: "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 Compensation laws of California." ,(, Signed.-------- ----- -- - F..... - Owner 8y... - ` r- ----------- . _ .... Title ------ .._._....- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--- --.. . . . _- -- --- DATE _...---- ---------- - - - -- DIVISION OF LAND NUMBER ..... ....... . ------ ------ ---------------. DATE..- .._.__......- ADDITIONAL COMMENTS. ------------- _ -------- --- --------..... - ------- -------------....__-------------_-. .... -------------------- --- ------------------------------ - -------- - - -._. . - - ...._..._.:. ................-----------------------------...:--------------------- - --... - .. -- . -----7---- ------ \ - Final Inspection by:....Ar --------- - - ------ - - -----------._._Date -----------�01- �.!. . -_........ ..... M 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M