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FOR OFFICE,USE: FOR OFFICE USE: V/APPLICATION FOR SANITATION PERMIT -------------------------------------------------- (Complete in Triplicate) Permit No._7k_._l /___ -------------_---------------------------------------_--- This Permit Expires 1 Year From Date Issued Date Issued_.f�0=_?8' 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: / C JOB ADDRESS/LOCATION_,:'' Zd ," lf/ .CENSUS TRACT.-----:-- -------- Owner's Name. ----------------------------------- - -------------- - - --- --------Phone -- ` Address - r-Z/f---------------Zip--�r 5-7- - } "� - ---------------------------------License :#r`_------ --------Phone---a'_3,�--"-- �r. Installation will serve: Residence"Z Apartment Contractor's Name .�' '--- --=------=--'- �y�, House.❑ Commercial ❑ Trailer Court ❑ k r Motel ❑ -Other------------ -----------------` = I ,�, Number of living units:------ ______Number,of,bedrooms-__ _:____Garbage Grinder-____-,___;_Lot,-Size' '. -.. �_,._.._ I' Water Supply: Public System and name-.--.,-----:'----:-• --------- ---- -------------------------- ---- ±---------- ------------------------- Private . I Character of soil to a depth of 3 feet: Sand ❑ •Silt❑ Clay ❑ Peat 0 FSandy Loam [] CIay�Lodm� ] �_ M Hardpan' Adobe FiII Material_ I - p ❑ 2 ' -If yes, tY_pe--- ------------------------- 7 " ! �i .7 ' + 0 (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 pub[ic sewer is available within 206 feet;]: PACKAGE TREATMENT` �"'' ^ _ ��''" Liquid Dep f ts- Ca acityf��-- - T e.-- - --�_ �-- `� -- ----- -- - - - � th----�<�--�---- [ ] SEPTIC.TANK ['] f- - -- _ Size-----, _- - - � - p Yp. �' ateriai' a'� C �Jo.?Compartments -- ------------------ Distdnce'to ----- -- Distance'to nearest: Wells.__. -Q _ ._: F ndati Prop Line ' ou on �` C� � LEACHING LINE [ ] No. of.Lines .; �__-_-_. Total Len th-----------17 , --__:_ p �__-__.: _ _•,Length of each line g � • -_ 'D' Box -Type Filter Material_�1.F__ ;/&Aepth filter Material__„--_-_1'1-.---_____________-------------------- --------- _ `---`______---- _. Distance to nearest: Well__-__ Q_`_____- ____Found ation-__. ?-�l___________i__.Proper`ty Line_.._____ _-___ b ._.-i. . [ ] De th Diameter ------ Numberf. ...; SEEPAGE PIT p Number---------- ----------- --- Rock Filled . Yes❑ �No ❑ Water I i Table',-Depth -RbSize- = +--- - Distance:to1 nevi st:'Well_ ____:______ ---Foundation _. -----------------' Prop. Line ___ REPAIR/ADDITION (Prev. Sanitation Permit.#__------- ------ ---- -=-----------Date--------------------t----------_-----'-------f Septic Tank (Specify Requirements)----t---== - tom” } Disposal Field (Specify Requirements[ -- = -":_ `t ------------- s --- { ------------ ------------------- --- --------- t ----------------------------------------- ------------------------�{ sI -------------- ------- - 4.. r n (Draw existing and required addition on reverse i I hereby-certify that I have prepared -this application and that the work will be done in accordance with San Joaquin County i Ordinances, tate Laws, and Rules-and Regulations_ of the San Joaquin Local Health Disfrict• Home owner or lien ed agents signature certifies the following: : '"' . � "I certify that in the performdrice-of the work for which this permit is-is-sued, I shall not emp oy any person'in such manner as to become }� bject to Workntamp7s;tion laws of California." . "" 7 a r Signed ------------- ----- - - Owner ' BY '}- T� , /!=j. -----------------. :_Title-- s a ` - 1(If other than`owner) ' fQR DEPARTMENT USE ONLY: APPLICATION ACCEPTED-BY ------=----- ------------------------------------DATE 'S TDA' DIVISION OF LAND NUMBER - --------------------- --------`---------/ ------ -a -----DA ---- --- ;.� � -f; ------- ._ ADDITIONAL COMMENTS__ �----- --- ---------------- 'i - ------ ---- ---- ------- ----------------- - ----------------- ------------------------------------- ----------------------------------- ---------- --------------------------------------- -------------------- ---------------------- ------ --- _ -------- ------------- --------- ------ -------- - L \ Final Inspection by:. - �rrY�f J -------=--------------------------------- ---Date —f -------------- e" 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M