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FOR OFFICE USE: FOR OFFICE USE: ///APPLICATION FOR SANITATION PERMIT ---------------------- ----- ---------- 7,/7-3 (Complete in Triplicate) Permit No.. ... ................ --------------------------------------------- Date Issued_.3_--5'.-_?.,y _________________________________________________________ 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 No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION. l F < ----- �i0 --- - /P------ ----- ---- -------------- ---CENSUS TRACT Owner's Name.---- ------------------------------------------------------- ----------------------------------Phone-------------------------------------- Address......... .------------ ----- Address--------- L 0 ------------------------Cit -,0i4- -------Zi Contractor's Name--- LC >-- l� ar5 ------------------------------------ ----License #. 7 s`� Phone- a'__6 installation will serve: Residence g Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other-------------------- -------- ---------- ---- jIla ! Number of living units;--)-----------Number of bedrooms-,----_Garbage Grinder------------Lot ----- ------ ---}--------------------- Water Supply: Public System and name-----------------------___--- --------_Private Character of soil-a depth-of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ClayLoam -Hardpan ❑ Adobe ❑ Fill Material__...--------If yes, type_---_--._-------------_.--_--- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) .� PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-_��x_. __ -_ ''o------------------------Liquid Depth.-5---- --__---.--_-- Capacity� - ---Typr�, _e.. Material------------------------No.-Compartments------- to nearest: Well-_ ---/ 7 Foundation.-c52-4:2 ~Prop, Line_�LJ�____�r-. LEACHING LINE [ ] No. of Lines_-�-------------------Length of each line.____ ______.____.Total Length----_ _�� __.______________ � - T�.� D' Box. Type Filter Material_ ] ? h Filter Material------------ _JP>_Y______._._i_____________________ Distance to nearest: WellfrfT _ _____Foundation____. _ _. '�.l.Property Line-__ SEEPAGE PIT [ ] Depth----------------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth = ----------------------------Rock Size------------------------------------------------ '• _ ,� tea_ a �-l F Distance to nearest: Well----=--------------------------------------Foundation"---"S--------. ----.--- Prop. Line------'------.------------- REPAIR/ADDITION (Prev. Sanitation Permit#----------- '---------_t------------------------Date4------------_—---------------------------- ) li o Septic Tank (Specify Requirements)--------.-------------------------------------- - -•---------------- - ------------------------------------'--------------------- Disposal Field (Specify Requirements) '>=ti - -----------------e-------------------- ---------------- -------------------------- =----------- -- - ----------------------------- -------- --------------------- "------------------ ------------ -- ---------------------------------- i (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that th w rk 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 ceitify that in the performance of the work for which this permit is issued, I shall not employ any person in'such manner as to become subject to or an's pensation laws of California." = y ; Signed ' Owner . ,._.__ 4F By--------------------------------- ------------------------------- --------------------- - Title----------------- - ------- ---- --------- ------ (If other than owner[ FOR DEPARTME SE ONLY APPLICATION ACCEPTED BY----------- -- ----- -- ------- --- ------- - --------------- DATE.------ DIVISION OF LAND NUMBER--------------------------------------------------------------------- ---------.--------------DATE_.___-..______.___._ ADDITIONAL COMMENTS-------------------- -------------------------- -------------- ---------------- ----- -------- ---------------------------------------------------'---------------------- . r Final Inspection by � --Date------r2 ��'------------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV, 7/76 3M