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{ FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- - ---- - -'----------- --- 7 f{ `•.. (Complete in Triplicate) Permit No____________ _5 3 j 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�wwith County Ordinance No. 549 and existing Rules and Regulations: 7 -`S -----� -- �"_`�'.'` "'-- .CENSUS TRACT- JOB ADQRESS/LOCATION '. .,_ ---- ." - ------------ Owner`s Name------ /off ---------- • li' _ ;� ------ -------- Phone -i --- Address - `��` =�r w.. ------------------------ 1P ,--� City- -�- Z Contractor's Name -- --- `--------- c_ a_'f' License #--324F ---Phone---------- --------------- -- Installation will serve-._ ResidenceApartment House.❑ Commercial E] Trailer Court ❑ I ,.. 4- �. Motel '❑ Othier_ ------------------_-`---- -. �.. F ..». - Number of living units:__ ;_____Number.'of bedrooms...3.____Gara ge,.Gr-iradw=r`___-----Lot Size----- _ .____..- e $_ r Water Supply: Public System_and`name-..: :_ :.---- ----•- ----- ---- --------------------------------------------------------------------- Privat ec Character of soil to a depth of 3 feet: Sand ❑ '-Silty❑ Clay❑ - -�P.eat ❑ Sandy Loam ❑ Clay Loam t Hardpan [❑ Adobe_❑ Fill Material--,-- `-_.If ye's;type___ ------_------=--- -'-- (Plot plan, showing size of lot, location of system in relation to'vw511s,buildings; dfe.-Irtiust be placed on reverse side.) NEW INSTALLATION '(No`septic farik or seepage pit permitfed-if publi a er is available within 200 feet,] PACKAGE TREATMENT ' SEPTIC TANK' � ---------------------------r ------. ...--k Liquid D --------:--- ------ Size= .= CapacitY = - .......... TYPe i. Mateo ia` epth ' = "i.' ---No. Compartments - --- - --------------- ----------- - -Foundation.-<------------=------___Prop. Line---------- i Distance,to nearest: We �-;- LEACHWG LINE,_ [ ] No, of Lines.'--- --.- _._'.Length.of.edch,li _h_-__-- --Total length_____________ - D' Box -.-,Type Filter Material Dept'Fiiter]�IlateriaL.,______________ ------------------------- 0 -"_---- [ I i.._ , .earest: WelI i --F,ou�nElbt{on---=--rt------------ Property Line.-------- ---------- - .� Distance ton - •.. ± . _ ...e. . .�. .. i ' Y Depth- " a' SEEPAGE PIT [ j :__._Diameter_'_"F__._± :_hNumber______________________ ___ ± Rock Filled Yes ❑ No❑ s . ._. Roc ±z Water Table:Depth---------- -' :--' k,S e Distance to n 1.e6rest: Well ,. ,L '---------------- Foundation- = Prop. Line----- -------------- oj{ , s - --`---•---------- -REPAIR/ADDITION (Prev. Sanitatin Permit# .- __ - Date ; Septic Tank {Specify Regbirementsl----- ;=--------- j "- :. Disposal Field (Specify Requirements)-#-- f I - ----- ,�14_/- ,/-- - , --------------------------------------------------- ----------------------------------------------- ------ ------ -----=----------------------------------------------- ---------------------------- (prpw existing and re uired addition on revere side) ' I hereby certify that'l have prepared this application and that Ythe`work'•will be done l 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 certify that in the performance of the'work'for'which this permit'is issued, I shall'not'eirtploy any person in such manner as to become. subject .to Workman's _Co ensation laws. of California." t :-_ _.� .. .�. ._. Signed------ ---------------- -- r j itis 13 - - ,OWne�' t (if other than owner) l� 04 FOR DEPARTMENT USE ONLY. i / �' APPLICATION ACCEPTED BY _.._% - --- i - ---DATE _ _/.-°"-- i - � ------ APPLICATION OFLAND NUNIBER_�-�_�_ - ------ ---------- --------------------- - - -----DATE ------------ ---------- --------------------- ADDITIONALCOMMENTS - '----------------------=---- --------, ------------ ----=---------------------------- ------ ----- _ _ .;t, ------------ ----------------------------------------- f ,Y -�, _ . . -- ------ --------- - -- Date."-_ -(0 �f Final Inspectionfby= ` = - - C EH 13 24 SAN JOAUIN LOCAL HEALTH DISTRICT FLS 21677 REV. 7/76 3M L —