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0 � FOR OFFICE USE: r FOR bI�ICE USE: a . — ,;p. 1 t � � APPLICATION FOR SANITATION PERMIT ------------------------------ - 7�- S ---------------- --. ,= (Complete in Triplicate) Permit o-- -------------------- Date Issued___S_2"17_� 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. i This application is made in compliance with Count rdinance No 549 and existing Rules and Regulations: A JOB ADDRESS/LOCATION --._ _' + -.____ :__..'_ __.__ '---_Y_CENSUS�TRACT`_____---- ' --------- Owner's Name------------- /� . --- - ---- --- Phone ' Address------ ----:------------ ._ _� -- ----- Ci !� -- --- -- ---- Zi i ty p-- i Contractor's Namet*hVCa'4#+y4re_Q.-_ ,rr�f-J- ._0�V6r_ ZX/G______License #30. 63---- -___ __Phone_q/,C'_&CA-&?AP t Installation will server Residence (�j Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---=------------ - ----------------------------- _ Number of living units:.___--._�_ ---Number of bedrooms-___ ___Garbage Grinder--______=_Lot Size Water Supply: Public System and name ----- _- --.------------ ----------------- ----:-- ---=�t-- Private ER Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ " I Hordpan ❑ Adobe Fill Material-------------If yes, type----------•------ --------_------- (Plot pian, 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 N] Size-.--- -_._---4�y9/_GG,'---------- Liquid Depth---1`41,---------------- Ca pacity'- ---------_-Capacity- -----Type-----------------------Material- --------------------:---No. Compartments----------- ------- -2-----------------; [ v = Distance to nearest: Well------- -------------------- Foundation------- Prop. Line-.-------------------------. LEACHING LINE No. of Lines.--------3-----------------Length of each_.line_------- ---_---------Total Length ___________ i 'D' Box--;-, pe Filter Material------6f C__..TyQ'�1r-.Depth Filter Material-----t.-- ---------------------__.________-_-___-.------. Distance to nearest: Wel]_'--:-- ----�_._ ' r ° ) - � -- -•.=-.Foundation---= �'�--------------,Property Line--. -6' -�`---- ' SEEPAGE PIT [ ] Depth-----------------Diameter_ _______ __ ____Number--------------------------------- Rock Filled Yes L] No z • Water Table Depth-------2-c:_ --- Rock Size--- ----------------------------- -- ------------------------------- Distance to nearest: __ Foundation__:--------- ,_ � Pro � 1Nell-y-.--.. ''---------- -----=---------- ' p. Line---------------------------- REPAIR/ADDITION (Preva Sanitation Permit#______________----- -_:-------------------------Date-------------------------_;-1------------ ---- Septic Tank (Specify Requirements)---- _fAOo------ _I LG-1 _ ------ ! - --� --------------- a Disposal Field (Specify Requirements)-- ----r' L - Gl -S -^ --9�-' X 3_�� P----�----- ---------------1 ------ _F. 4 i f ---------------------------- -- = I (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 wit h 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: ' { 9 "I certify that in the performance of the work for which this permit is issued, I`-shaljr?not employ any person in such manner as l_ A to beco a subs t to Workman's Co=tion: laws of California." i Signed �- _ Owner By. ---- ------ -- --- Title -(If other than owner] `' 9 FOR 9#AAVAENh USE ONLY �+ R APPLICATION ACCEPTED BY.-- ------ = :' DATE --- DIVISION OF LAND NUMBER---------------- --- ----------------------- --------------------------------- --` DATE I-------- ---------------- �- r ADDITIONALCOMMENTS--------------------------------- ----- - ---- ----------------.------ --------------------- ------------------------------- ------ ------------------ --------------------:-------------------------------- ---- --------------------------------------------------- --------------------------------- i --- ------- - - a ------------------------------- ----------------------------------------- Final Inspection by:...----- -- ---------------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M