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FOR OFFICE USE:. FOR OFFICE USE: - APPLICATION_ FOR SANITATION PERMIT // Permit (Complete in Triplicate) Perm Date Issued2- 377 ------------------------------------------------------ -- { This-Permit Expires 1"Year From Date issued'',,-- Application is hereby made to the San Joaquin Local H ed th 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: A JOB ADDRESS/LO TION-------------_ }-N.- ^'d6_ -CENSUS.TRACT--------------------- i Owner's Name---------- gyp. ° _ ' P > � y ��ac�`*?----- -------- ----- - --- -------------------------- -- - Address - . . � ---- City ------------ ----ziP- . . ..... ........ l_. -�. F Co.ntractor's Name = ------ -- --- ------------------License #� � _5, ��Fione �:. ... . = 1 c _ . . _fir. r t-e:, ._• z Installation will serve: Residencartment House ❑�, .Commercial ❑ Trailer Court ❑ 3 3 i # L ., Y -.. �,: . _. ., �.. •" z• Motel ❑ . .Other � ----------=- -�-- --------- - =-=-- .. - Number of living units:--__._.�:_-_.__Number of bedr s __._ -,__Garbage Grinde�r�_"'____Lot Size___._-,�.._ --------- Water Supply: Public System and name _ -_'-____ �_ __-- - - - � �lJ - ----------------------- ----------------Private Character of soil to a_ depth of 3 feet: ; Sand ❑ Silt Clay E] Peat El Sandy Loam E] -Clay Loam E]Hardpan E] Adobe ill Material__ __ o 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: (Noan ;septic tk-or seepage ,pit 'permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [,`] i SEPTIC TANK [':] Y"Sizse"-- -- ------- _ """"� --- -t-f-----Liquid Deptli._._____---------------- Capacity __. c- Type Capacity ::_*,;... - -----"4---Material-=-------------------=---=No. Compartments-------- -- --- r , ----- -- --- t ound n.-- ----- -=----- -------------------- LEACHING ---------- ------- __. .:Distance to.nearest:.W' ef.l. -_____ ___-- -- .,._. / ."� �_._:_Foundation.-; ��: Prop- Line LEACHING LINE No. of Lines------------- - _ .Length of each linal3' - "-_____:___._______..Total Length.: t, i # D' Box------ __ Type Filter Material Depth Filter Material .... I : i__. ' Distance,to.nearest:.WeiI ---- f .__ Property =---- »_. Fou Line �- Foundation_., _ ' Pr � SEEPAGE PIT - [ ] Depth.... , ._.D,iameter .--Number .__ - -_-_-- : Rock Filled Yes'❑ No ❑ Water Table Depth-------I�------------ ---- -------------------Rock Size._ -- { }Distance to nearest: Well--- ------_---------------------------------- ;Foundation--:------:------ ----Pro-p. Line-.------------------ _--- REPAIR/ADDITION'(Prev. Sanitation Permit#--+-- --------------- -------Date-------- ---------'-----'------- ------------------,------------ Tank - -) Septic Tan p �(Specify Requirements) _. ..._- ----------- --------- ---- --=----- -------- --- ------ --- --------- ------- Disposal Field"(Speafy•Regairements(:_ � ----- j- - ---------------------- . -------- , ------ ---------- --------- - --- -------------- ----- - ----------------------------------- - ------- - ---- ------------------------- - ------------------------------------------------------------------=-------------------------- ------ j (Drawiexexsting and required addition on reverse side) I hereby certify that.l 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 "t certify that in the pei•formdnce of:the work for which this permit is issued,.) shall not employ any'persori in.such manner as to become 'subject ,to Workman's Compensation laws of California." Signed------ = OwnerZZIt : �NBY -= r / = ----- -- Title__ : r- ----- ---- ----------------- ---- -------- -.------ (if'other than owner) ;. OR PEPARTMENT. VSE ONLY APPLICATION ACCEPTED ----------------- - -- - DATE.. . - = ----.__--- DIVISION OF LAND NUMBER.: ------ ---- ----------------- DATE-------------- 3 -- - ------------ ADDITIONAL COMMENTS------------ ----------------; ---------------------------------------------------------- ---- =------------- ------------- ------------------ ----- w_ . ---------'------------------------ -------- t -- ---- ----- ----------- _ Final^ p ction"by:- -- 1 ------------------------------------.�--------------------------------- ------- Date. t -------------------- "`'E" 0 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M