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+OR OFFICE USE: t FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --` X7337 - ~ �« GQ.�.y ------ (Complete in Triplicate) Permit No--- --- -------------- ------- ------------------------------------------------- Date Issued_.. .�_z. �_�� ...... ____________ _____________________________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin LocalHealth Districf or,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- ,2�7L � ,L� /e �"� � 4 ye------ r CENSUS TRACT Owner's Name /l iSrLl�fl '- Phone T4�� - -- Z --------Zip.-q :----- , .. ' �' _. Contractor's Name_____________ ------- - C;rW -----License a -------Phone----- ------ ------- Installation will serve: Residence' ❑ Apartment House 4 C m rcial ❑ ` Trailer Court ❑ ` ] --�- Motel-[]--- C)*,e -�� _ - - --------- -- -- 020 V ' Number of living units:____ ______-Number of b4qd"riit- Garbage Grinder____________Lot Size__ _____�__�_f_4Z__.___.____._____._.______ ------------ WaterSupply: P_ubJicSystem and name___—___ _ ________Private ❑ ------------ UUU Character-of soil'to a depth of 3 feet: , Sand ❑ Silt❑ Clay ❑� Peat ❑ Sandy Loam Clay Loam HardparcL10- 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.) NEW INSTALLATION: (No septic tank or seepage pit-permitted if public sewer is'-available within 200 feet,] Jr - - --- -- PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth.____'__-_____._____._____ Capacity--------- --- --------Type "'------Material._ -----:-----------------No. Compartments---------------- Distance to nearest: Well----- ----------------------------- ------Foundation-----------------.--------Prop, Line--------------------------r LEACHING LINE [ ] No. of Lines----------r------------- Length of"each ling-------�f�---------:-:--Total Length _---.-------------------------------- 1P 'D' Box------------Type Filter Material----------,:.____---Depth Filter Material--------------------------- -------- --------------- Distanceto nearest: Well---------._-___-__-_____._Foundation____________________________Property Line--_.--------------_------------- SEEPAGE PIT [ ] Depth-------- -------Diameter Number________________________________ Rock Filled Yes ❑ No [� Water Table Depth---------- ... ------- ------------------Rock Size------------- ------------- Distance to nearest: Well -----------------------------------------Foundation--------------------------Prop. Line---_--_.____.____._._..____ REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------- ----------- -----Date----------------------____-- ----------_-- ) Septic Tank (Specify Requirements) ----------- -------------- ----- ------ "p " �f : ��.. Disposal Field (Specify Requirements[--��^.�. �'"'e----- --------------------------- -------------------------------------------------------------- " ---- -�.�- --- ---- -- (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. Horne owner or licensed agents signature certifies the follawingi "I certify that in the erformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subiect o Work n's Co pensati laws of California." Signed-----i_ By-- -- -- ------------------ ------------� ------Y- --------.Title-- w ------ (If other than owner)- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------'-.- --------- ------------------ -----------------DATE 2. ._?.' ------------ DIVISION OF LAND NUMBER ----- ----------------------- -------------DATE------ ---------- --- ADDITIONAL COMMENTS- --- ------------------------- ------ ------------------------------ ------------------------------------------------------------------ ----- --- ------------------------------- ------------------ ------------------ ---------------------------------------------------------------------•--- ---------- ----- --------------- ------------------------------------- -- -------------------------------------------------------------------------------- --.] --- - Final Inspection by: ---- - - ---------------------------------------- Date-------- 7 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 t