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ye FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Q Permit No.- C_ ------------- -------------------------------------------------- - -- ------------------- - [Complete in 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 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...._ g3o ' -----------S-4------14-F a /hCENSUS TRACT.- Owner's Name ---" --------------------------- -Phone-------------------------------- Address-------------------- - rvs g,. City It?a"z �a---- ---------------zip---�=5-.3.30 --------- Contractor's Name---- ---S.eLF'----------------------=----------- ------ ----------------------------License #----------- - ---Phone---------------------------------- Installation will serve: Residence [X 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❑ 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 [ ] Size----------------------------------- --_liquid Depth ---------_------_-----_p� Capacity---------------------TYpe --------- ------------Material.------------- ---- ----No, Compartments---------------- ------------------ Distance to nearest: Well----------- -----..�.--.--------.----------Foundation.------------ ------------Prop. Line----------------------------Q LEACHING LINE [ j No. of Lines-.-_------------------------Lenn'th•of eachilina--------------_-_._.-_--Total'l-een th-_T.---- _.-_-.--.------------_.-- W g g _ D' Box Ty_ e Filter Material-----;--`- `---- -Depth Fitter Maerial-------------------------------•-- .------------------_- [ ] Depth ce to nedresameter_ - i------ NumbFoundation----------'---`---------------Property Line.----------------------------------. SEEPAGE PIT j� Di ` k i 41e ------------------ -- Rock`'Filied Yes ❑ No ❑ _ . c Fil Water Table Depth--------------------J---------------l-- --------------Rocl. ize Distance top nearest: Well---------J...1 1 f -- ---Foundation--.- -------- ----- Prop. Line--------------------------- REPAIR/ADDITION ------ ----REPAIR/ADDITION (Prev. Sanitation ii Permit#----------------- E ----------------Date/ ---------------,---------------------------.-) Septic Tank {Specify Requirements)-l--. ---------------- ---- ------ } - - Disposal Field (Specify Requirements ---Ac4--------1`I C LI N)-a'------I"j;0 r ------ - aszEM------------------------- ---------- s� t ------ ----------------------------------------- ------------------------ t...wr ---------------------------------------------- - ---- °---------------------- - --------------------- Q- -- �- `� !-/_�a---oc - - - --- --- - \;{Draw existing and required addition on reverse side I hereby certify that I have prepared this.application and-#hat 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: � 4 "I certify that in erformance of the work--for-which'fhis perm[ 'is issued,-'l shall not employ any person in such manner as to became b' sut t Workma ompe 's Cnsation laws of California:' f t Signed------------------------------------------------------------------- ------------------------------Owners By------------- -- --------------------------------------- ------------------------------------- ti. ..iTitle---- ;--------j---------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY[ !, APPLICATION ACCEPTED BY------------_ .___ — __ ------------------------------- - - ----s-- - --�- - - � n -- ATE - ----�----- w--� ------------- DIVISION OF LAND NUMBER----------------------- --------------------------------------------- ` - -- -- DAT;=�-:_ - ADDITIONALCOMMENTS----------------------------------------------------------------- --------- --------------------------------------------------- -------------------------------------- ------------------------- ------------------------------------ -------------------------- ---------------------------------------------------------------------------------------------------- -------------- ----------------------------- --------- v --------------- z �------------ �JOAQUIN - ------------- Final Ins ection by:- -"------_ .A_ EH 13 24 LOCALS14EALTH DISTRICT F&s 21677 REV. 7/76 3M