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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit --------------------------------------------------------- •------------------ ------------ ---------------.---.-- This Permit Expires 1 Year From Date Issued p Date Issued./--3_- / 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/LOCATION---------- _[._ ------ ....... _,T/171 � gP.- ----------- CENSUS TRACT. Owner's Name------ '`° �:- - -- -------------------------------- -------------------- ---Phone_--_J0,2_ _U z,2�----- arr Address_- /.` '�3 JI� �` -------------------------- ......Ci ---------------------- Contractor's Name---- ------- j 1' :,. -_r --------------- ------------------License #-e 75-6-.v-�-----Phone_Z57_�-�� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------ --------------------------------------- Number of living units:--/------------Number of bedrooms-3------Garbage Grind ------------ ize--_ f�-_ -- -f-- ---.----._- -------- ------fG Water Supply: Public System and name----- Lz•'r--`----------------- ----------------- ------------------------ -----------------------------------------------Private F-1- A Character of soil to a depth ofd-feet: Sand E] Silt❑ Clay ❑-�y Peat EJSandy Loam`❑ Clay Loam El.�_� _ _ _ Hardpan ❑ Adobe E] Fil! Material'..-- __w_-if,yes, type_______________�'-,-----,_----- a (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 public sewer.is available within 200 feet,} PACKAGE TREATMENT ( 1 SEPTIC TANK I l Size a�?��",�-�---:_.-� _ ---------Liquid Depth ��- --------- Capacity/AO`s--------TyPe.C'9G��?< Material - ----- 4-No. Compartments-------Q---- ----------------ISIZ f . Distance to nearest: Well--- -------------_- -------------- ' k ' Foundaton../a-.----__-----w-- Prop, Line_____ ----------------�j � �LEACHING LINE Na, of Lines------ - ----------------Length`of 6dch line...--- --------------.Total Length.------- ------ If il___--. _J_iD' Box---- __----Type Filter Material-l .Depth Filter M ` Distance to nearest.. -� _ _ Foundation -- -----Property Line.--- ----6----------------------\ SEEPAGE PIT ] Depth----------------biometer---_.--------- -----Number---------------a---------------- `r Rock Filled Yes ❑ No WaterTable Depth------------------------------------------------------- Rock Size------------------------------------------------- Distance to nearest: Well-------------- -- -----------------_-----Foundation.-'-._- ' Prop. Line. REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date_t-- ---__'_-==----- '--'------------M Septic Tank {Specify Requirements)----------------------------------------------------------------------- - ----------------------------x' . ,v i .,. Disposal Field (Specify Requirements)------------------- -- ----------------- ------------------------------------------------=------ ---------------------------------------------- --------------------------- - ----------------- (Draw existing and r"equired"addition on reverse side} *� I hereby certify that I 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 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to�or y an s mpensation laws of California." Signed ---- ----.4-11,A� ---- -'--az ,/k.-�- --------------------------------------Owner Ile By---- -------------------------- Title.------------ --------- -- ------------------- -------- -------------------------------- -w A- -(If-other-than owner) y. - --�+ - --�--- -- �` FOR DEPARTMENT,USE ONLY APPLICATION ACCEPTED BY --`- ------ - ------------------------------------------------------------ DATE---- DIVISION OF LAND NUMBER--------------- -------- ----------------------_---- -------------------------- -----------------.DATE-------------------- ------ -- - -------------- ADDITIONAL COMMENTS----------------- ------------ ----- ------------------------- ------- ------------------------------ ------------------------------------- // 7 Final Inspection by:------------ - Date L ��--f -- --� - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. J7,/76 3M