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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------- n- -, ' Permit No.-.7?—F.° 3 k . ri' .7. � {Complete in Triplicatel4 ------------- --------------------- i D' �' �7 Date Issued_ -_ .._ ----------_____________________.____._________._____.__ This Permit Expires 1 Year From Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit t 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/LOCATIOP4 �_'-�� ------.CENSUS TRACT------------------- ;----. Owner's Name---------- P 'c, -t1 --- ,---------- - Phone t. ; „ .:._ Address f �.�c__ .__._} ' -zv cz G z` (' ----------------- City, z�sa.2. --Zip Contractor's Name........ s:c.c:G�_ -:__ ` ---------License # . ____ _PhoQP-----------------------------_____ Installation will serve: Residence [ Apartmenf House E] Commercial ❑ Trailer Court L] t Motel ❑ Oth,er ` Number of living units '__:: ____Number of..bedrooms:_.�___._Garbage Grinde.r.__ --Lo.t_Size-______..�.._=,.,-_._!..__ Water Supply: Public System nd name-:--,7-.--,,- -- ------ ----- ---------------- --- '-------`-------------------- � � t ---Pry ivat Character of soil to a depth•o'f 3 feet: - Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam l Hardpan [] Adobe Fill MateriaL_._........Ifyes, type___ ---------- L� (Plot plan, showing size of„lot, location of:system in relatio6towells;buildings,,etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank .or seepage pit permitted if`public`s�ew�er.is availablee withiri200 feet,)' PACKAGE TREATMENT` [ }- SEPTIC TANK ("] Size_________________________ Liquid Depth------------------------ .p Capacity- ----- -------------Type----------------------:__Mate,rial----'=----- ----- _.....No. Compartments_-------------- ---------- i: Distance to nearest:'Well____________________ ____ Foundation __•.__..______,Prop. Ltne LEACHING LINE [ ] Na. of Lines_,____ _------_-------------Length of each line: --------------Tota Length ------------------ - D' __ Z QBoz_ }--- __Type Filter Material_-- p Filter Material_.'__---- _----------------------------- ---------------- 4� . -. . .. � ...._ � ---Foundation .... .. - i Distance to nearest: Well-'---------------------- ---------- ------------ Property Line--,------------- ------------- --- __. SEEPAGE PIT { ] ' De th__. __,:__:_._.Diameter___________________Number__ ; Rock Filled Yes ❑ No ❑� P t : , -. . .. -------------------- Water Table Depth ---------------------- Rack Size_ 1 rDistance to nearest: Well------------------------------------- -----foundation-----------------------.Prop. Line---------------------------- REPAIR/ADDITION {Preva Sanitation Permit#__ ______..__________ ___ ___ ____ :Date_.____:____.__:____._____.___._'___________) - -------- Septic Tank (Specify Requirements)- =:= --------- --------------- -------------------------- ------------ --------- -------------------------------------------- i Q Disposal Field (Specify'Requirements)__. _------------------------------------------ -- '` ---------- ..-- ' `' ` '� �'/ = J - "rte,l ` . --- -----= ------------------- -------------------------------------------- -------------------------- ------------ ------------------------ ------------ j (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 Coun _.; Ordinances,' State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents 1 signature certifies the following: , "I certify that in the performonce of Ahe work for which this permit is issued, •1 shall not employ any person in such manner as f to become subject to. Workman's Compensation laws of California." l Signed-- --- --------------------------------. . 611 -- --- ----Owner . . . � # I. ; BY : � - -.T--------- ------ -- ------------ ------------- -- -- ---- Title �•t # Of other than owner} i FO DEPARTMENT USE ONLY° # APPLICATION ACCEPTED BY- -=---DATE.',h__ DIVISION OF LAND NUMBER...-- = = --- DATE------- ------ -- ADDITiONALCOMMENTS----------------------_--------------------------------------------------------------------------- ---------------------=------------ ..-----5 Y - i Final=inspection-bY--�--.- ------------------------------------------------------------------------_ -.-- ------------------------------- - ---------------------------------ate JO Ell 13 24 S AQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M