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1 FOR OFFICE USE: ;r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------- -------------- ----- lCorriplets intriplicate) Permit No.zv,IO8"e2 - Sr i ------------- ------------------ -_------------ 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/,LOCATI N-...- � l�L�� - � - -4--��- �-,- _ S TRACT ----v-------------- Owner's -------Owner's Name.-.- - - - --- ----- .- ..�.-.,-,--�:- - -"r t ,! . - - -•�- _--rte- - - - - t `-------------------- --- _Zip---- - ----- ----- Contractor's Nal'ne m 7Z ` �� c �_- = �-/--- -License #--- ` .__Phorie-------------- - Installation will'serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other_--------- = . . t, Number,of.living units:--------- ------Number of i bedrooms.-__3-__Garbflge Grinder------__ =-_Lot'Size------ ..., ------------_---------------_---_------- Water __ _-Water Supply: Public System,and name_ __________ __r_____. _ _____-_ - ____-:__ ? Private t . --- P ' e Character of soil to a depth of 3 feet: c Sand ❑ -Si.lt❑ • Clay ❑ Peat❑ Sandy Loam [v' 'Clay Loam-E] ` Hardpan ❑ Adobe ❑ Fill Material--_______.._!f yes, type-- ------------ --- I (Plot plan, showing size of lot, location of system in relation to wells, buildings etc. must be placed on re erse side.) r NEW INSTALLATION: ,(No-"Septic tank or seepage pit permitted if publ!.ie'sewer is_axailabke with rj-200 feet) ` PACKAGE TREATMENT [ `j SEPTIC TANK' Depth_:._ _ ------------------ Type. 'Material--- '� �--__ No. Compartments-_-_'.?---------------- CDisti _ p ance to nearest: Well. _ _Foundation _ _------ LEACHING LINE, [ No. of„Lines-----_---u3--=------------Length of each line------Ee-_�--------Total: Lengtff__+-_ '-f ---------------- ' 'D' Box /-.'__Type Filter Material _ -_--Depth Filter Material-^�__=_ _______- Distance to near gst: Well � _ � i e y.---,�d��_ .Foundation .__fc�.�-_!__ Property--Line-;-_��`_,��- ____ -� SEEPAGE PIT 5� �k: .k .v---r� ti --------- SE -� Rack Filled Yes No ❑ t [ I Water Table'De th__________ ___ _----------------------------- _ __Number �-_._____ �-- -_ , De th. Rock Size------- _ 3 j piame er- :----.- --- - - - - - • .. Ristanc'e.to nearest: Well `---------------------------- --------------------- ':------------ -----•=-------------- --- Foundation------------------------ Prop'., Line------------------------- REPAIR/ADDITION ------------- --REPAIR/ADDITION (Prev:Sanitation Permit#----- ---- --- -------------- ------ .-_ Date______________________ } ' -------------- Septic Tank (Specify Requirements)-_ --------------------------------------------------------------- Di sposal -------=----=---_-Disposal Field (Specify Requirementsl'--------------------- ___ ` - ----------- - ------- - - 2 . ., , ---------------------------- --- ------- ------------- ------------------------- [Draw existing and required addition on reverse side)' I hereby certify fhat 1 have prepared this application and that the ,work will be done- in accordcince with-San Joaquin.Cou6ty _ Ordinances, State Laws, and Rules and Regulationi of the San Joaquin Local Health Districf,,Home owner or licensed agents signature certifies the following: "y "I certify,that in 'the:"performance of'the•work fai. which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation;laws of California." Signed-------------- ---- - = : '/ -------------- ---------------------- By_ Own r -}r Y (If other than owner) t ; WR DEPARTMENT USE ONLY" ~ - . .;. ` !�_ . . r APPLICATION ACCEPTED, $Y '. - -- -- '_ - fir" --= DATE. L-_ ------ -------------- -- DIVISION OF LAND NUMBER-------- ------ ------ - - -------- `'�; DATE ' --- -----:�:= �' ADDITIONAL COMMENTS----------------- s = i i 9 ------------- ------------ ------------ --- - -- ------ ------= = ----- ------------------- ------ - - _______________________________________-________.. ___._ _____---_ ------------ .---- -" Final-Inspection by:-_ � � --- - Date.Z� � � = -- EK 13 24 SAN JO QUIN LOCAL HEALTH DISTRICT F&S 216 77 REV, 7/76 31