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'FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- (Complete in Triplicate) Permit No..7-�_w___.3.3 - - - -------- -.. Date Issued-��--> --7? -- This Permit Expires 1 fear From Date Issued I i 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 A b ESS/O TION. . -- --=----- '��' --` --------..CENSUS TRACT------'- -- ------ --- ---- } �• Owner's Name -- - ------- - _ Phone /�a_-:d-7 -- . . r Address--- � -- --- -City---. zip - --x7.-3 ' t Contractor's,Name.-_. t ------=------=------=------=-----License # `r .. -Phone-. -- `1RAta[lation will erve: Resi a ce,K. Apartment House 0 Commercial ❑ :Trailer Court. ❑ ' .Motel ❑ Other--- ------ - -------- --- ----- r Number.of living units:-------------------Number.'of.bedroom s'�9-�.-Gtar bd a Grinder...----------Lot Size------------------------------------------___________--- ] Water Supply: Publ i�c System"and'name----;------°----------------- _ ;_ Private - ---- ---- --- -- Character of soillto a depth of 3 feet Sand Qrsi-tt`rrr .Clpy F-] Peat❑ Sandy Loam Lj Clay Loam ❑ I 1 --- - �FI I'M`aterial:f —,.If yes, type-------------------------- i- Hardpan Adob5e -.---- 4 ]Plot plan, showing size of lot, location o#'system in Tela#ion o wells, buildings, etc. must be placed on reverse side.) ; NEW INSTALLATION: .(Noi septic' tai4r- br seepage pit' permitted "if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ]..:I�EPTI'C TANK ( Size-- -------------------------------------- ------Liquid Depth----------------------- • t . V/ t . ..- acifi e -- Materia! = = = No. Com artments-----�------- Ca p. y- p a - tl I . d / 1 Q } ;. Distance to n. arest:,Well____ _ ______` " Foundation__ _-______--__-_Prop:.Line__ _--_ _______--._----.` LEACHING LINE~. [ r ----_- _ ] No.�of�•L-ines'��.-----:;-':-::-------Le�gtlsaf,�each line.-��:---,.---------------,Total. Length ,��-a-�--------- D' Box--/ -.- Type Filter Materiel. Depth Filter Material _ - -- _ �n Distance to nearest: Well-:--------- -- -- --_--- --------:_'�_Foundation----------------------------Proper'..ty Line--=-------------------- �,.. -'--i SEEPAGE PIT ] ] Depth- Diameter______________.____Number___ ___------------------- Rock Filled Yes ❑ No" All Water Table Depth : --- Rock Size--------------------- -------------------------- --------------- ---- ------- ----- I Distance to nearest: Well-'------------ ----- --- --------------Foundation.-+----------------___.--.Prop. Line.----------------------:--� (Preva Sanitation Permit#______________________ _•__ .___.___.Date---------------------------------------------- REPAIR/ADDITION ) .47 Septic Tank {Specify ----------------------------------- Disposal Field (Specify Requirements) = f- - -----s------_-- - -1 x .41 # l .t .. ------ -- --------------------------------------------------------- - ---------- 4 a ; {Draw existing gridequired addiaion 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, Stdte Laws, and Rules and Regulations of the-San Joaquin Local Health District: Home owner or licensed agents signature certifies the lfollowing:" t "I certify thavih the performance'of:the'work for which this permit is issued, t shall riot empl y.'jj: ,,person in such manner as to become .subject to Workman's C mpensation low s�of.yCalif orgia." 5 Signed B � ------------------------------i 'Title. BY � L kY--------- -------- ------- . -------- --- -------------- ------ ... - , (If other than owner) t �FOR DEPARTMENI`USE ONLY ' APPLICATION ACCEPTED BY_ j DATEr ' DIVISION OF LAND NUMBER -------------= ----------=----- -----.DATE-------------_------ - :- - -----: - ADDITIONALCOMMENTS -- --- ------------------------------------------------------'----- --------------------------`------------- -------------------------------------------------- -------------------------------------------------- ----------------- ---------------------------------------- ----- ------------ - --- -------- ---------- I --------------------------------- -------------------- -------------------- ---- ------------- ----- -------- ----------------------------------------------------------. -- --------------------------------- - --- ----- - - - ------------- -------=------=------------------- Fina[•Inspection•by:==' ' T = _ ==` ____-- Qate... `� ---- --------- . � EH 13 24 , SAVJA UIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M 1 '