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FOR OFFICE USE: FOR OFFICE USE: i APPLICATION FOR SANITATION PERMIT Ii (Complete in Triplicate) Permit Noz___-n4_3__1 + Date issued- ._-_--.---.----_---_-------------------_--_----__---.--. 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. 5-49 and existing Rules and Regulations: ...� _.. $ -:� _ - --� M - -- _--CLNSUS'TRACTx"-�--- JOB ADDRESS/LOCATION_ i - "' Owner's Name------- - --- --------- - - --------- " Phone. - i .I R - - .. - Address------ ---- ----- ------' �j---� ----- = 'y�`� 4J- --- --- "-- .City-"--'-'--�%�'r''�� -Z�p Contractors Name.-------- - -'---- - ------ -- ----- =-"---- ---'�_�4-License #---��..�•--�-ZP�� Phone------------------------------ Installation ------- --- -------- ----- - Installation will serve: r Residence [!f. Apartment House-E] Commercial ❑ bTrailer Court ❑ Motel ❑ Other--- ------ Number of]iving.units:___ -----------Number of.bedrooms.--.��,--.Garbage Grinder------------Lot Size.- - ._ -r Water Supply: Public System 'and name- ----- ---- • ----- -------------- ----- - --_------ ------------Private a Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ : Peat ❑ Sandy Loam ❑ Clay Loam ❑ (fj ' Hardpan ❑ Adobe( Fill Material-___ _ �_If yes, type___: - (Plot plan, showing size of lot, location of system in relation to wells, hu.ildings, etc, must be`placed on reverse side.) NEW "INSTALLATION: :(No='septic tank sor see - ge pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ 'I"T SEPTIC TANK "[' Size-: '2.-X--! _ _4'_-_--_:'-=': =-'Liquic! Depth.-___/74________________ Capacity="� "9_ Type : Material-_ --No. Compartments `- --------------------- 1 o Distance to nearest: Well-... S a_ ............ .Founddti n_ 1 a Prop. Line____ --- 17 / LEACHING LINE [_ Na."'Of.Line .._- -:•,� -- :- Length of each line. art. - ,-�,-_-Total Length 1 7_p_. s D' Box 1----Type Filter Material - ---- A ----- -}------- -------------- Distance - -- • � _De Depth Filter Material _'- � -- -____ �_ Distance to nearest: Well-:__ __ _______________Foundation--.- .--[A_._' Property Line____-r'_-------_----------f © r J` t '?� k_ ��' Rock Filled Yes Z No SEEPAGE PIT [ "Depth...-�--- -.-_Diameter_-____ '��--.Number ----� 4 . Rock Size°s' � - 3 -----------=ater xle Ditanetoneaesf: Well."--'------- ------ :Prop Liner' 5--------------- REPAIR/ADDITION , (Prev.,Sanitation Permit# " =°= =:-:Date ------------ ) WA-17A .,:;vim ' •. - Septic Tank (Specify Requirements)_ : s ` -----. ------------------------------------------------------ Disposal --------------------------------------Disposal Field (Specify Requirements)------------- ----_------------------:--------------------- ------------------ '---.------t------.------=+ ----------.-.. i ------------=-------------1---------------------- ------ _ -------------------- ------------ - - - --------- - ------------------- ------ ---- ---------- I ----------------=-----------------------------------------------=---- - =" - ► - (Draw existing and required addition-on reverse side) i { I hereby certify that.1 have-prepared ibis 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: ' F "1 certify that in 'the performdhce of'.the'.work for which this permit is issued,'l shall not employ any person in such manner as to become subject to Workman's Compensation laws.of California." Signed = ------------ ------------ ---------- -Owner -. - BY ----- ----- - ------- --- - Title-.- � _ (If other than .owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,'BY - °- ----- ' ................. =--------------------------DATE.-- �T = DIVISION OF LAND NUMBER-------;-------.-- ------ --- - --------'-- - -- - - DATE -�:--.-------- - -- =--- ----------- ADDITIONAL COMMENTS `r --------------------=- -------- --------- --------------------- ----------------------------------------- --- 1 -- O - ---- ------ ------------------- ------ - - ------ ------------------------ "' QLi - ------ - _ --•---f ------ ------------------ --'-- --'---- - -----------------•------------- ' Final Inspection by:- 0 -- - ---- ------------------- ------Date------- "�-- -------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M