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G 1w► •W FOR OFFICE USS: FOR OFFICE USE: /APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -"l//_3 --------------------------------------------------------- ----------------------------.......__.__.-------------- This Permit Expires 1 Year From Date Issued Date issued.J,1-/.97Jb' ft.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- --- ----- -------------- --- -- Owner's Name-----a� - V -------------------------------------------------------`-- 5 �5 Address___ e - - - City-4 Cct 1� -- ------------------Zip---------- ------------- ---- wo Contractor's Name--C[�� ---�G1�G.(Z .-- ^-iS - ----------------------------License ----,--- -Phone--17-D1-41--------- Installation l -Q1-- - ---------Installation will serve: Residence ❑ Apartment House.❑ Commercial [�K Trailer Court ElMotel f_1 Other---- -----------'-- --------------- ------ Number of living units:----------------Number of bedrooms------------Garbage Grinder------------Lot Size-----------------------------------------------------__--- Water Supply: Public System and name--------------------------------------------------------------------------- --------------_---------------------------------Private Z r Character of soil to a depth of 3 feet: Sand C3' Silt❑ 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,) c � + \ PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Siz ---- -----------------:------------------- __Liquid Depth---4 __.__.___.._._.__O Capacity---p-------TYpeS: 's =----------Material �{;^^�Y� .__-_-No..Compartments--- --------------------------- Distance to nearest: Well._;be._ ___Pi'_,______-____.___Foundation------ --------------------Prop. Line_204)_ - LEACHING LINE [ ] No. of Lines-____\----------------------Length of each line_-10a-__ ___._.___.Total Length.__)60__ -'__._________________ oType P Filter Material Mteal.- _ - - Disance to nearest: Well-_200IV-_ _ Foudation_ = Property Line___2e=p --------------- SEEPAGE PIT [ ] Depth.____._..---Diameter--------.__--------Number----- _____________ ------------- Rock Filled Yes ❑ No� ..� Water Table Depth_----------------------------- ---------------------.Rock Size--------------------------------------I------------ Distance ---------------- =---- ------------------------ Distance to nearest: Well----------_--------.------.----------------Foundation---- ------------------._.Prop. Line_------------------------ REPAIR/ADDITION _____. .REPAIR/ADDITION (Prev. Sanitation Permit#._.________________________________._.___....__-Date.._.__.______--___._____- -------------- Septic ..__- _____Septic Tank (Specify Requirements)--------------------- --------------------- ------------------------------------------------------- -------------------------------------------------- Disposal ---------------------- - Disposal Field(Specify Requirements)__.-________...._ _________________.________________._-___-_._-- ------------------------------------------------------------------------- r. ------------------------------------------- ---------------------------------------------------------------------------------------------------------------- ------.----------------------------------------- ---------------------------------------------------------------------------------- --- ---- ----- (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--------------- --------- - --- ---------------- ------------ - -----------Owner .r By--- 1rC _ /�' ----Title_ 1rt (If other�i:ter) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -`----- - ' -- - -=- 1-------------------------------- ---------------------------DATE.---- ----- DIVISIONOF LAND NUMBER------- ------ - -- _ ----------- ----- ---------------------------------------------DATE---------- ---- rADDITIONAL COMMENTS-----------------------------------_-- ------------------------------- -------- ---------- ------------------------------------------- -- ---------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- -----------------------------------------------P-, ----- ----------------------------- ---------------------------------- -----------------f -- - -------- -- P Y - Final Ins ection b - - - - - Date Z�I-7i_�? --. . ._ . _..... . ..... . ..�. ._,. ....._....._ �o� .,.<„ oma„ ,,,<�..