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t�• r FOR OFFICE USE: --- —FOR— APPLICATION FOR SANITATION PERMIT t k (Complete in Triplicate) Permit No.17-r--~. ..�.5 Date Issued.f�._.3.._ ....................-------........-......-- This Permit Expires 1 Year From Date Issued- Application is hereby made to.the San:Joaquin Local He I h ri or armit to construct and install the work herein described. This application is-made incompliance with County Ord'n c No. 5 9 and existing Rules and Regulations: JOB ADDRESS/LOCATION:... SSI_ .1/(.�0_r•--.... .... "'..CENSUS TRACT..-............................. f Owner's Name._......._`: _.Phone_-4f6 � 7..1.......:_._ ........ .................... ...-- Address ° :/�' City._. .. zip :.. - Contractor's Name ...... . i �S 3 3 ....... ----- ------ - ............... ........License Installation will serve; Residence' Apartment House ❑ Commercial ❑ Trailer Court ❑ / Motel ❑ <Other........'.. ...............................Number of living units:- --..f.........Number of bedrooms.-- -- ..Garbage Grinder------ -.---Lot Size.__. S- - Q ------------- t Water Supply: Public System and name....... __- v - ti ' Private Character of soil to a depth of 3 feet: Sand E) Silt ❑ Clay ❑ Peat ❑ Sandy Loom I] Clay Loam ❑ ^Hardpan ❑. :. Adobe Fill Material t# 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,] Liquid Dept h.-PACKAGE TREATMENT SEPTIC TANK Size....... .- --- - ....... - A CaPacity .Lpv1 .----..Type -- Compartments.._... �---- --" ------------ Distance - - --...Distance to nearest: Well....... .....:_- --- ......Foundation---- Prop. Cine...--5-_.:'- LEACHING LINE No. of Lines --.-- ...-. -` �Q ....--. 0 --- ---- of each lino...-......... ..... ..__Total Length ------ -- ---- ------------�- ' 'D' Box___._<.Type Filter Material.. ...__ ._...Depth Filter Material.......l.k........ Distancato Barest: Well,... _.. __.__.-Foundation._ 116-__.' .-_. I Property Line... _..'t�............... SEEPAGE PIT �Of Depth __ ..Diameter.. Z.��.._.....Number___ ._._?1___._ ._ Rock Filled Yes , No ❑ 11 f if ll Water Table Depth......... ... ....... ...... . Rock Size.....-17.. ...... .. 1 p /�. r ....� ................... r Distance to nearest: Well----.._..._/-.S_V..............___----Found ation-----.. (_6_ "_ __ Prop. Line_..... ._........ REPAIR/ADDITION (Prev. Sanitation Permit#----------------- -- ....._......Date-_.-:_:.---_..-..---- } Septic Tank (Specify'Requirements).----- -- ---._. --------------------- Disposal Field (Specify Requirements)"t:__ --_.'- -----•----• ---------- --- -------------- --------- - ......---................ ----------------------------- _ - :.. -----r------------- 'P"""' (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: "1 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 By..' - . .'...._ .._... Title.. (If other-than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------��'.... ................. ...... ------ -- ....---------= . --.....DATE ......... R .. DIVISION OF LAND NUMBER DATE---------------- . _.. , .;. ADDITIONAL COMMENTS.. ------------------------------ ...........:..:.... .. _ ---:. ._ Final Inspection by:-.- SAN JOA UIN LOCAL HEALTH DISTRICT Date. ://� ^� EH 13 24 (,� ISTRICT F&5 21677 REV. 7/74 3M