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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit -----••---------------- ---------------------------- •-- �y ---•----------------- -------- ----•-----.---••-•-.- j This Permit Expires 1 Year From Date Issued 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.... �$30 ?6 ---....---&'----- � _A�1 . ..�.,r rvc ..1 A4 --------.CENSUS TRACT . --- . -- Owner's Name La a_G,o �eL-�va-- --• -- -----------Phone...-•------...._. Address _ ._ - ---- ------ -- e-------------- _. . _�1a„Z4,-a .. s 3 36. ....Zi City. . P--- Contractor's Name _S.e�LF-------- -------- ----- ._ - _-- ----------------------License ------_----- -------- --.-Phone------------- - Installation will serve: Residence CA Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.................. Number of living units:....I----------Number of bedrooms----Iq...Garbage Grinder._._ ._ _-_Lot Size....-.-------_--------- ------------------------------ Water Supply: Public System and name--- ----------- --- .......... - ------ --------------------------------- .---------- •-•----Private Character of soil to a depth of 3 feet: Sand ® Silt El Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT ( ] SEPTIC TANK I ] Size---._---- .................................. ........... liquid Depth. -. . _ _ Capacity-------_---------_-Type__.. _ -- -- ..Material.. -- -- - - . __No. Compartments------ ...._G� Distance to nearest: Well..............................1,.__ Foundation .........................Prop. Line-- .... _ ... Q LEACHING LINE [ ] No. of Lines--------------------.-------.Length-of eachiline-----------.------_-.-.__--TotalLength_ ------------------------_- 'D' Box_..- w-Thi? Filter Material..... `. ._ .Depth Fitter Maierial...................----_---_._ Distance to nedt'a'st:•We9f--- —.-..i...............Foundation......---.'.t_-------_-Property Line---..........----_-----------_----- SEEPAGE PIT P 1 ik I I r� . Rock"Filled Yes ❑ No E]( ] De th---- _ ._.c,�Dipme(er .. ....-L ------- Number----------------- - Water Table De th-----•-- ---- f J..! Rock.Size._. .. 1 Distance to nearest: Well.........1+... ............. Foundation Prop. Line......... ..__------- REPAIR/ADDITION (Prev. Sanitation fflPermit#_ ....................) Septic Tank {Specify Requirements).1._.I �_____ _ ................. ----------------------------------------- ---- Disposal Field (Specify Requirements,---- --------- -_- .lila ----_� / cD ---------- �` �- L Ll.fl_ ....... s..t $�...a_C ---- ---- --------- ------...................... ------ y.9... ..., \.(Draw existing and required addition on reverse side) I hereby certify that I have prepared this.application 6nd-4hat the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules arjd Regulations of 'the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: ',] ` "I certify that in ;rfrmance of the work mor which fhs permit is issued,'1 shall;not employ any person in such manner as to become sub t t rkma 's Compensation laws of Californidr" rl �J i Signed---------- -------- ---------- -r�--� Owner` 1 By -- -- - ----- ---------------------------------d----------- ..,Title-- ------I------------------------� FOR DEPARTMENT USE ONLYi --- - -- - --- (If other than owner) j APPLICATION ACCEPTED BY........ . y..YLrlt-`- - ..... ....�'. _. . " -,. :��ATE - ...... ? ------------- DIVISION OF LAND NUMBER._ ------ - DAl` r. ' - ADDITIONAL COMMENTS.......................................... ----------------- ----------- r' --------------- Final Inspection by: - -- --- ---- --- ------ ------- EH -----EH 13 24 SAN JOAQUIN LOCAL?1fEAL1H DISTRICT F85 21677 REV.7/76 3.M