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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit o______________ ------- ------------------------------------------------- __ _------------------------------------------------- ---- Date Issued-- -------- 7,2 --------- --------------------- -------------------------------- -- This Permit Expires I Ye-a7r From Date Issued r7 k Application is hereby made to the San Joaquip 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: , t} ; JOB ADDRESS/LOCATION. - �NTy---- ..i' U-C_ ------ I1�`f ----` .CENSUS TRACT__------------ ------------- K� Owner's Name----------- P- T _fiirQ .iS_N - ---- --I----------- ------ -----Phone__9-57/- - --- -•- acz7C} City Nl ---------- Address Zip Contractor s hame_ t �-1 .N__-` `" n��i :_ ,-,-- -k_--_.-_ n - '!� License # _ Ph'one--- ----__-- __- �� -- Installation � � l � 3 wilt.serve: I Residence " Apartment House.❑ Commercial ❑ Trailer Court ❑ 8 Motel ❑Other-----------------" --- - 1 L_ y. 4 #w - . Number of living units:__ I__Number oT bedrooms_-�____Garbage Grinder___._.-. Lot Size-_,_---, --------------------- ------------ T __. . -. Water Supply: Public System,land name = _ r . ------------- - - ------------------------------Private ❑ Character of soil to a depth of 3 feet: Sad ❑ Silt❑:`_Clay ❑ ; Peat❑� San y Loam ❑ Clay Loam t i Hardpan 0 `Ad"obe Fill•Material ----- f YbA;t e____-_.__'_.-__-______. .. (Plot plan, showing size of lot,^location of.`system in relation to wells, buildings,:etc�must be placed on reverse side.)ir ; s--5- NEW INSTALLATION: (Nod septic tank_or seepage pit permitted if public sewer is available within'200 feet,] PACKAGE TREATMENT I I I SEPTIC TANK j I Ize-----------------------------`' _______ Liquid Depth--------- ------------------ Cap' city- __-_____CapcitY- s _- : _No. Compartments .r- _. t--� Dist6nce_to_nearest:Well Foundation— -- ---- --Prop. Line----------------------- t---� LEACHING LINE [ ] No. of.Lines -------- _.-.,_--:Length of each,line-------------------------'----Total Length ---------------------------------------— i t 'D' Box------------Type Filter Material--------------------Depth Filter Material----------------------------------- - : _ ------_-----Foundation------------------------------Property Liine.--------------- - :-- --- ------- SEEPAGE PIT [ ] Depth Distance'to nearD ametel r...............::....Number------..--_--_---_____-_-_--____ Rock Filled Yes.❑ No ❑ r Water Table Depth---;---------- ---------------------------------------Rock Size--------------------------------------------I------ Distance ----- `---------------------------------------- Distance to nearest: Well----------------------------- ------=----=-Foundation--------- ---------------.Prop. Line-------- -------------- REPAIR/ADDITION (Prey. Sanitation Permit#_- _-.------ - Date-------------------- - ) >► ---------------------------- ------------ Septic Tank (Specify Requirements)--- E 1 :. f-� * :-- ----- = _ -----------' ------=- Disposal_ Field (Specify Requirements).- _CSL e ,k� LaN--%----------/ X �' ------------ --- --------- ' 1 �- -. - q -------------- ----- ------------------- ------ --------------- ---- ------------------------------ -------------------------------- •--.------ --------------------------------------- -------- ---------- (Draw existing and required addition on reverse side) t 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: . t "1 certify that'in the-performance of the work for which this permit is issued, Fshall not employ any person in such manner as to become subject pCalifornia." - -- Workman's Com a tion laws of California Si ned_. ` _ B ------------------ t. • ' !u Tit I Signed--IDI .?-�1 2-1.S''f-fi. I ----=- ----------- _,- ----- le._ � �r��4J o (If other than owner) .' ' " FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-, r •�+�_ -----------------------DATE------3- ----� ----------------------------- DIVISION �7------------------- -- DIVISION OF LAND NUMBER------------------- DATE___________________ ___ ---- --------------------------------------------------------- --------- .-.. ------ ADbfTIONAI COMMENTS------------ - - -------•------------------------------------------------------------------ j. ----------------------------- ---------- ----------------- ---------------------- ---------------------------------------------------- --------------------- ---------------------I---------------- ---- --------------------------------- -- ---------------------------------------------------------------------------------------------------------------------------- ------------------------------------------,----=--------------------- ------------- Final-Inspection bY=--------------- ----- --------------------------- ----- Date 7 .. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M