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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- Permit No.__yZ__�� - --- ------ � (Complete in Triplicate) - -- y - Date Issued--- ____-- d -------- ---------------- ----------- ____ --------------------- 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..N.o.-549-and-existing Rules and Regulations: JOB ADDRESS/LOCATION,,.__ _ 3-- - 1-----------------`----- ---- -- .GENS ACT Owner's Name- ---- ----- ----- ------ --- - ---- o :: Address R 1 Z' �` x=: t��-,�� --- ------------------- City` Zip �� /� Contractor's Name - !� ` ._K - License # �7 Phone- _ Installation will serve: Residence ( ! Apartment House.0 Commercial ❑ Trailer Court ❑ M`o`teI C] Other----- '---- i------------ s__ - Number of living units:'._:___,l_______Numbert of..6edrooms___._._Garbage Grinder------- ----Lot Size-:............... Water Supply: Public System and name ""^'�_ ..: ....- -----, �._:- ----, _----.._ Private ti"1 Character of soil to a depth o#•3-feV-Acl61�e rand ❑ Silt❑ Clay"[a.,_rPeat ❑ iSandy Loam 0 Clay Loam ❑ ! 'Hardppn 0 Fill Material_.._. __If yes, type] -------- ---- -- r (Plot plan, showing size of lot, location of.syster in relation to,wells, buildings, etc. must be.placed on reverse side.) NEW INSTALLATION:' " (No septic tank ,orfsee age pit permi#ted if public sewer is available within 200 feet,] ; PACKAGETREATMENT 1-1 " SEPTIC-TANK-['[ ] Size_ / _. - -__: ' -----------------Liquid Depth-. ------------------------- t ----------_________is Capacity-A- ) aterlaL_ - -_____No. Compartments------ ------------------------ Distanceao nearest: lea, .--- - -._Foundation---_-- -.-.Prop. Line_ 2--5., LEACHING LINE [�JNa.-of LiJnes.______:7_- .--._.:,_;Length of.each line...- p, .,:-._.Total Length __.._� P_ ---------------___ N. ! I 'D' Box_ l _.Type Filter Material �....�3,� __Depth Filter J�laterial ___-_I ___ _ _-___.______ V . . ;_.. .i - . I # -__- ! ! ¢ a ` _. r ,. Ze Property Line ��!"C ----- i Distance•#o nearest: Well :1 .. .Foundation . 4 n I SEEPAGE PIT lDepj� _-_Z- DiameR ter !.___ ` Dumber_ _;___ ; Yes [ No ❑ .j3:._ N --- -_,- Rock Filled 1 Water Table be' =�{�" l Rock Size_- l i .!! ------------- P _-Foundation_ : f Prop. Line ! I Distance to�riearest:Well_..___a , __;_ _ 7' REPAIR/ADDITION [Prey,:Sanitation Permit#--:_-.------------------------------------ ';_iflate--- --.-=-_- ---- Septic Tank (Specify Requirements)---- ----`-- t-==------= -- --------------------------------------- Disposal Field [Specify Requi'rements)... ... ------ ----' ------------------ -------:--------------'--------- --------=------ - ---------------' -----`------- ---------------- - _ -- ----- -- ----- . ---- ---- i {Draw existing and required addition.on rev. se side) I hereby certify that I halve,prepared this application and that the .work will be done in accordance with San Joaquin County Ordinances,' State Laws, and Rules and Reguicstlons of the, San Joaquin LocaliHealth District, Home owner or licensed agents signature certifies the 'following: 9 "I cern that in the erfor}narice of-the work-for" which-this permit-is-issued, I shall not employ any person in such manner as to become subject to Workmon's. Compensation.lawis -of ,California."_. Signed - --- M _ weer Title. uIf other thari"owner- ` FOR.DEPARTMENT USE ONLY` APPLICATION ACCEPTED: BY-.--_:: ---_---- -� _ - "----7-5 i `- = - ,.------DATE------- =---- ----------------- _------- DIVISION OF LAND NUMBER.-_.___;.____;'__ ADDITIONALCOMMENTS--- ------ ------- ---------------------------------:----------=--=------ ------------:------------- -------------=------------------------------- -- ---------- --- --- I -------------- ------------------------------ --- ----- ---- -------------------=------------------ ------------ ------------------------------------- ---------------- -----=------=--------------------- -------------------- ------I------------------------------------ ----- --- -------------------------------- -------- ------------------ 9 - ------------------------------------------ ------------------ -- ----------- ------ Final-Inspection b - .... ------- 677 Date-" EH 13 24 SAN JOAQU LOCAL HEALTH DISTRICT �2 677 REV. 7/76 3M