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FOR OFFICE USE: FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT -------------------------------- ......... . Permit No.7e.:1',0,9':b (Complete in Trip +tate ----------------•-• ------- -------------------- Date Issued-&�_7d-7 ----•.................... This Permit Expires 1 Year From Date Issued Application is hereby made to.the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliances' ith County Ordinance No. 549 and existing Rules and Regulations: ` JOB ADDRESS/LOCATION. �(�-� ._. 11 �' !5.�..�0• . - CENSUS TRACT.........:..... ) Owner's Name.... ...... / � --...-:......_ ................. --...._... ------ ..... ------ ......... ......... Phone. ' �-------� -4), -- ......-Zip--�? Address---------• Contractor's Name :...._ -..._ •--.....-- __.. - ---� -------------- --.License #- --- Phone_.......----------------- Installation t will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ----- •-•-•---- �) iSizeL Sl fir: Number of living units;.......-/------Numb:er of bedrooms...._o�-..Garbage Grinder-------------Lot __-.--+ Water Supply: Public System and name-1- _. -------.------ ---------_-------------------------------Private Character of soil to a depth of 3 feet: :Sand E] Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam.❑ Hardpan ❑ Adobe ❑ Fill Material._ .__ ....lf yes, type-------------------------------- ~" F (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, 3 - --- ' __Liquid Depth.... PACKAGE TREATMENT SEPTIC TANK Size------ ----------------------- ---y-u"::-1-�s Capacity-/,?a4-----Type � ...Material_..� �r_:No. Compartments------=- ------ -�- ; . �• ; Distance to nearest: Well........... Foundation.-.. 0..........Prop. Line-.../?-S, .....::.: .. LEACHING LINE [�¢, No. of Lines.............�-. .... -_.._.. -____-_..Length of each/line.-.--------��...._.. ...Tota! Length _ ..--�-�G..----.. . ')' 13 ..--.1..-:Type Filter Material,$,a r=�/b�a!�Depth Filter Material----L . --------------------------- ------ OXi Distance to nearest: WeIL_��-D-O�-.--- ---.- Foundation------->/-O------- Property Line.., ....... SEEPAGE PIT De th_, Diameter_....; 1.---....Number ---------- --------------- Rock Filled Yes ❑ No ❑ •- .Rack Size. '_.... Water Table Depth----------------_-/0-0--- J.,... / __....Foundation----. - i Distance to nearest: Well.__._____. . -5�-- 7/Q.- Prop. Line._...a. . 5 'l REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------- ----------- ---------Date----------------- ---------- ------------) Septic Tank (Specify Requirements).......:.............__. . ----- ---._-----. I Disposal Field (Specify Requirements)........ ............": ........ .. ----- . ---------•-••---_ _..__.. -------- --------------- -------- ---- - ------------•-------••-•---- ---...._- -------- ----------------- ! --- --------------- ---- (Draw existing and required 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, I shall not employ any person in such manner as to become su ct to Workman's Co pensatian laws of California." Signed:---- ---- -- - _ -•-------------- --- ------ Owner --. -- Title--- -- ---- -- •----- (If other than owner) FO DEPARTMENT USE ON Y APPLICATION ACCEPTED BY------------ ---- •---- ----- - /l :..... . t' --- . ----- -.. .---DATE...... -- .-... ........... DIVISION OF LAND NUMBER._....7.-'--q.L --- DATE ADDITIONALCOMMENTS_. ---------------------- --------------------. ............_....._...----- ---- ---- .............. --------- ---------- :. ..................... .. ....... --------- ..... -------- ------ ----_........--- _.... C3. ...... ....__...... .- �.. .............................................. Final inspecon b - ---- --�Date 21677 REV. 7/76 3M-- ---- ----- EH 13 24 SAN JOAQUIN LOCAL HEALT DISTRICT