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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------------------------- - - (Complete in Triplicate) Permit No------ ----------------------- -- ------------------- ---------- Date Issued_.__.-a_?'�? _________________________________________________________ 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 Ordinanc No-549 and existing Rules and Regulations: JOB ADDRESS/LOCATION- L ----------^- �-- --�f' _:- -_�_ .CENSUS TRACT---�.1------------------------- -------- -_�1_------- -.---. Owner's Name _... - -¢ ---------- - ---- Phone j .. �. ..-...�..'. .. -- r ." --- - �! . Q� �'� 7 : - --- ----- ' City- _ Zip- Address License Contractor's Name.... ✓Lrzi=E. -- --- -- - -- t.----- #_.1 rY ---Phone--------------------------------- Installation will.serve. _ Residence [Apartment House.0 Commercial ❑ Trailer Court ❑ a Motel [] Other-=--=----------------- --- .. Number of living units:--------f-----Number of bedrooms::_..__Garba.ge Grinde�r___:______'__Lot Size___.__�_�3__-' 'z��`�."______________ 4__- Water Supply: Public System and name___________________________________ ❑ ------=---------------------- - --Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay (Peat ❑ Sandy Loam ❑ Clay Loam ❑ s Hardpan ❑ Adobe Fill Material-----------if yes, type-------------------------------- (Plot plan, showing size bf lot, location of.systerrilin 'relation towells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic �tank .or seepagelpit permitted if public sewer is available within 200 feet,) � � PACKAGE TREATMENT [']' `SEPTIC-TANK [`�]-"• ' Size-----'---------------------------------- -------------------Liquid Depth.-------------------------- I Capacity----= --------------- YP I' ------ --- __ Type ____- � � _ Material _ -'_____:_ No Compartments ______ _ ..-Distance to nearest: Wel11..0-s.. __a_s.4_J_---------------------'Foundation - __ _ ___----------Prop. Line---------------------------- LEACHING -__---__---- -._..LEACHING LINE_ [ ] No. of Lines Length of each lineL_u `�_____ Total Length __ ___ ' ______ } 1 D' Box ------`__Type Filter Material------------= Depth,61.TerrMa ial----------------------------- k-1i /--- ------- - .. _. , _ Distance to nearest: Well____}__ _ ___:_____________Foundation--- -------:k------------P-roperty Line _ ---------------------------- ;17 � f SEEPAGE PIT [ ] Depth____ _..........Diameter--------------------Number__<< `.___:_-____ Rock Filled `:Yes-:❑ No [] 9' Water Table Depth.-- -----: �: _-- ---- _Rock Size, __-- -_ --: l t - Distance to n,&6,rest; W611' -------------------- ------ --- _'Foundation.__ ______._____ ____:..Prop. Line------- __ REPAIR/ADDITION (Prev.!-Sanitation Permit#-:;------'--------------------------- _-_----.Date------,.___------------_--_'_----_"' — Septic Tank [Specify Requirements] _ -------------------------------------- i - .. Disposal Field (Specify Requirements) __________________ ____ - : . ,. (Draw existing and quired addition on reverse side! = o- I hereby certify-that-l-have-prepared-this-.application-and-that-the-:work--will-be~-done-in-accordance F with-San-Joaquin-County Ordinances, State Laws, and Rules,and Regulations of the Sam 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 sliall not employ any person in such manner as to become subject to. Wor ompensation laws of California." Signed = i-- Owner BY = _._--'_LG-Y--------------Title.__ r I (If'other than owner[ FOR"DEPARTMENT USE ONLY APPLICATION ACCEPTED,BY- -- - ------=------='-------------------------------------------- - - DATE �' --------- ----------------- 7 7 DIVISION OF LAND NUMBER.----- =------------- -DATE-'- --------------- ADDITIONALCOMMENTS-----= ------------------------------- = ---- -------------=------------ ----------------------------------------------------------------- -- ------------------ I -------------------------- - ---- - - - ---- - ----------------------------- - - --- -----------_ ------,---------- - ---------------------------------------------------. .----------- ---- -- ----- ---------: _ ------- ------------.---------- ---. i --- • ------------------------------------------ -------•- ---•------------------------ - -------- -=-------------------------------- --- --- ----'-------.------ Final Inspection-by:--------- - ---• ---- - ° =-----=------ = ' --------------Date_. _�� 717--------------- i - - EH 13 24 ff SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M i t