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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Complete in Triplicate) Permit o----- Date Issued_. "_�'-____/' ----__..____________________________________._.___ ---- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for perm it.to construct and,install the work herein described, This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ' /4 --JOB ADDRESS/LOC�rTI,ON..d �.�1"n(P---------------`:--------- -��-' --�-. ------_------_.:----,•...CENSUS TRACT./� Owner's Name. 11�i4 _�v'. ,�CJr ---------------------------------------- Phone- ! /_'J�. Address= 1 �1�r City......�7 �6---------------- �a *-- - " " Contractor's Name__4�.. *r'r.f •G,-____-----------License #_. P ______Phone: � ` -� Installation will serve: Residence impartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ---- ----- ------ --------------------- Number of living units:-------_--------Number of bedrooms-----------Garbage-Grinder--Lot Size--------- .__.aXZ..T�415___--------------_----___ a Water Supply: Public System and name-------------- --- --- - ---------------------------------------------- --------------- ----------------------Private -! Character of soil to a depth of 3 feet: Sand ❑ Silt❑ -Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ _ + Hardpan ❑ Adobe E] Fill Material--.------.--If yles, type------------------------ - -- �_,- # (Plot plan, showing size of lot, location of system in relation to`wells, building, etc. must be placed oh reverse-sidL-)- NEW INSTALLATION: e(No septic tank .or seepage pit permitted if public se-weir is available within 200 feet,) PACKAGE TREATMENT [ ]' , SEPTIC TANK [ ] Size---------------____________� '_�___=______-___ ----- Depth.__________-_----_-_--- Capacity = Type " Material --------------No. Compartments -- ` ----------------- ------------- Distance -- ( _ Distance to nearest: Well_.------------- __ -- -_ —Foundation-..___._.-------_ I --•--=- Prop,Line---------'--'----------- LEACHING LINE [ ] No. of Lines_„----------------------------Length of each lirie,--------------l' -------------Total Length'_I___________________________________ --------' `- M 'D' Box-. _ :_.._ -..Type Filter Material.____ _ ______________Depth Filter Materlbl__>____ ._ -- ---------------------------------_ € Distance to nearest: Well----------------------------Foundation-----------------_.y'-----Property Lihe----------------------------------5 I SEEPAGE PIT [ } Depth----------------Diameter.--_-__.-----------.Number---------- --------------------- Rock Filled Yes E] No Water Table Depth ---------- ---- --- -------------- ----Rock Size----- --- -------------- --=---------------- Dista'nce.to nearest: Well—-----------':----------------------------Foundation------------------------..Prop- Line--= -----------------_"-_-. REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date:------ :-- -----_�__----_ Septic Tank ) ,_.. -�_- y 4_ v�_. _ [Specify Requirements) p = - -------------- - ----- ----- ------'--------�= ------ -------==-------------:---- ---- --------- Disposal Field (Specify Requirements)---------dU- ----- -/_P. ----- 1.�Y ----- --- fC_/b! -��----- ------f�t _f -------- � � � - �� --------------- ----- ---=---------------------------------------------------------`------------------------------ -- ------------ (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 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 orkma 's Compensation laws of. California.". Signed---- ------- ------ ----------- ---- -------------------------------------- ---------Owner -~- 1� r f BY --- ---------------------------------------'---------- Title PiL- -----' ' F .. .. .# ._ ---N, ` (I other than:owner) ;FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY:- --=------------ `----------------- ---- DIVISION OF LAND NUMBER--------- ------------------ ----- ------i------------=--------=--------- ' -----.-:- ---.---:- DATE------------------------------ -- -- ADDITIONALCOMMENTS-------------------------------- ------ --------------------------- -----=------=------------- -------------------------- ------- ---- -------------------- ----------- -------------------------------- , Final Inspection by=---------' = Date_ .. _ EH 13 24SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M i