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FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT r FOR OFFICE USE: ---------------------------- ---- --- ------------------- (Complete in Triplicate) Permit No____��_-!4G/ __ ----------------- ---------- ------------------------ Date Issued..3'-0' 9-�' -----••--------------------------------------------- ---- This Permit Expires 1 Year From Date Issued 7 [Lor Application is hereby made to the San Joaquin Local Health District for a permit to construct and install aEertBpi b d.1: This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulatis. RESS/LOCATION-JOB ADD - _ ---011 TRACT // + ~COwner's Name.: .------ -.__ Address-----------0- / ---------- _ ,� ---- s�c� City I. zip ------------------------- Co ----------- - ntractor's Name-..------r— .- _ . . - _.-- ��'-.&7. __ _-_----__License #----- Installation will serve: Residence Apartment House.E �:E_Commercial ❑ Trailer Court ❑ Motel E3 'Other------------------ Number of livingunits:__a _ ____-.___Number of bedrooms._. _., g u t' �. Garb e Grinder---- _-_---Lot Size--____--�j� -- --------------- Water - =----- ---Water Supply:-Public System and.name --------------- 1_ _!/ f_ '"- -- p. PrivateI _ -, . . _ f Character of soil to a depth of 3 feet: Sand Silt.❑ �!Clay�� Peat[]'Sandy Loam ;: Clay-Lodi Hardpan ❑ Adobe:❑ Fill M'dteraal - : -----if yes;= .pe-!-----.,. .---------------- ; (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(ta--nk or seepage pit permitted if publiE seweriis available within 200 feet) i PACKAGE:TREATMENT [ ] SEP.,TI TANK ®CJ� � � �. � [ '] Size Li uici De th_ � r � ��- � 1 Ca aci ��--:T e__ "�. P tY ! YP '=-Material Q �Q _No. Compartments-----------�-_------ ---'- Distance to)nearest: Well \" - i.Foundaton Prop. Line _ LEACHING LINE [ ] Na. of Line'`s ._ .: `: Length_oeachline ;__�� ('_ _- TotalLength�: /�- -- -- D' Box__ Type Filter Matenal / ,/ Gpth Filter Material.-____-__� __. _____________# � ! ---- I VI Distance to nearest: Well-_-��. ______Foundation---- -----------------------Property Line______ ..........._ SEE-PAGE PIT [ ] Deptli;_ -----------Diameter----- ___.Number--------------------------------- Rock Filled Yes.❑ '.No)n„ Water-,Table:Depth---------------- ------------ ---------------------Rock Size------- -------------------------------------- -- i. Foundation nearest: Well- -- ---------- - ------ Pr p. a ----- �o Lin REPAIR/ADDITION (Prev. Sanitation Permit#_ _____________ -_ :Date:__._- , 4 Septic Tank (Specify Requirements)----------- -- -----------= `= ------------------------ Disposal -- ---- Disposal Field (Specify Requirements).-------- -- -- -------- -- L r ;_ - = ------------= ------------ (Draw existing and required additionon reverse side}. hereby certify that'l have prepared this application and•that the' work°will-be' done 1h'-accordance,with •Sam Joaquin County:; Ordinances, State Laws, and Rules.and Regulations of the San Joaquin Local Health District. Home owner or licensed agentsi signature certifies the following: - k "I certify that in the performance of the work for which this permit is issued, 1 shall riot employ any person in such mariner as to become subject to Workman's Compensation laws of California." - . . a ; Signed-------- -- �- - ----i��;1------------;------�--- ------------------------------Ow.ne --Zi t Y BY-•-- .� ----------------------- Title--- s -- - ----- - .------ ---------------- (If other than owner) "'r - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED; BY---- DATE. r DIVISIONOF LAND NUMBER._ --------=------------ ------------------- - ----------------------------------------- -------------DATE.---------------------------------------------- ADDlTIONAL COMMENTS ---------------------------------------------------------------------- ------------------------------ -- - ---------------------------------------------------------- ------ -------------------------------------------- ------------------------------------------------------------------------------------- ------ - ---------------------------------- ---------------- ---------------------=----------------- - ,f , Final Inspection by:--- _ ------ -------=--------.-------------------------- ---------------------- Date - = i . .-_ EM 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S?46AREV. 7/76 3M'