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FOR OFFICE USE: FOR OFFICE USE: (Complete in Triplicate)TION PERMIT APPLICATION FOR SANITATION --------------------------------- ---- Permit No,2—F 3 p p nate} ------------------------------------I------------------- Date Issued_&w:,,P-F.:7. t ------------- ---------- --------------------- 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._r_3z- F5---- �1--------- CENSUS TRACT Owner's Name.----- �t�7 /� ----------. -Phone--------------------- ---------------- / Address--- ---------U0 ----------------------- -- ----- City--��- ----------- --- ---------Zip------------------------------"'"� Contractor's Name_________ ----- --._License #_. .ZZ Phone------------------ ------ --- Installation will serve: Residence ❑ Apartment House❑ Commercial ❑ Trailer Court Q Motel ❑ Othe'r:___.____ Number of living units:._—------Number of bedrooms_.--,-:: Garbage Grinder_--r____Lot Size___... �-�-____,.___ -- Water Supply: Public System and name--------------------------- -------------------------------------------------------------------- --------Private 27r, Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material___--------- f 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,) t'`3 1141 PACKAGE PACKAGE TREATMENT [ ] SEPTIC TANK [✓J/ Size_ '. '_'._ "____✓__ Liquid Depth.' '______________ Capacity_6 4b-p.-------Type. .- Matarial� _No. Compartments----------- --------------------- Distance -`--------------- j Distance to nearest: Well_____-----------_S e.________--_i` --Foundation.._.---J_d---_________Prop. Line_______-------___.________.S LEACHING LINE [ No. of Lines-------------S___________-Length of each line--------- .-___-____.__.Total Lengtih,-__._... 0_c--_.___.______________ 'D' Box-----I-----Type Filter Material'._,. --------Depth Filter Material------1_q ----- ---- _ � Distance to nearest: Well_____1 ,90 E___--------------Foundation_-------1_b_-------------Property Line_______-_.___________- ---- -. JSeEPAGE PIT [/] Depth___P�_^S._.__.Diameter.____.______Number-__________ Rock Filled Yes No E] i Water Table Depth----------------7 p----------------------------------.Rock SizeJ,9 ---=----=---------------- Distance to nearest: Well------------------------ _ _ Line...� ----------------.20 v . f REPAIR/ADDITION (Prev.(Prey. Sanitation Permit#---------------------------------------------------Date---------------------------------------------_) Septic Tank (Specify Requirements)----------- --------------------------------------------------------------- --------------- ------------------------ -------------------------- 'Disposal Field (Specify Requirements)------------- o ------------ 1 - - -------------------------- ----------------------------------------------------------------- ---------------------------------------- ------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------- ---- -- --------------------- (Draw existing and required addition on reverse side) F I-S 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 subject to Workman's Compensation laws of California." Signed --------------------------------- ----------------------Owner BY------- ------------ ---- --- ---- ---- - ---�-s6- -'a--------------------- �l� d ---------------- -- -------------------------- o` . (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------�.'- ' - DATE.�� "-2.-- - DIVISIONOF LAND NUMBER----------- ---- ---- ---- ------ ---------------------------------------------------------------- ---DATE----- ----------------------- --- - -- ADDITIONALCOMMENTS----------------- ------------------ ----- ------------------------------------------------------------------ ----------------------- -- -------------------------------- ------------------------------------ ---------------------- -------------------------------------------- ---------------------------------------------------------------- Final Inspection by Date ! ._... ------------------ - --- -- -- ----------------------------------------------------------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M