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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- (Complete in Triplicate) Permit No.- ---------------------------- ----------------------- ------ This Permit Expires 1 Year From Date Issued bate Issued._ Application is hereby made to the San-Joaquin Local Health Disjct for a permit to construct and install the work herein described. This application is made in compliance.with County Ordinance hto. 549 and existing Rules and Regulations: JOB-ADDRESS/LOCATION. - �. - i .CENSUS TRACT i Owner's Name---- Pon ; =�,_/ ------- . Address_____ ___-3_ d t ----- - P I City Zi t. i �. ► .. .,._ . ------ . ------- Contractor's Name - ----� '<cr .]/Er:=-.� :_.. License #3:71 (' - ❑ x - .... - Phone_. -------- Installation will serve: Residence f� Apartment House❑ Commercial ❑ ' Trailer Court Mote! .❑: . .Other:= =='= = ' Number of,living units:__ .r----------Number of bedrooms_.,,,3----Garbage Grinder___:___-.---Lot Size____________ ________________.__-.--,--------------------- Water Supply: Public System and'name - =-------------------------- = Y = Private U Character of soil to a depth of 3 fe;/Adobe Sand ElSSiltr,� Clay ❑ Peat❑ Sandy Loam E] Clay Loam ❑ _ .__ Hardpan E] Fill Materidl._._'' If-Yes,--type-•-t---i___.__..____________. �! (Plot plan, showing size of lot, location of system in re'lation`to wells, uildings, etc. must be placed on reverse side.) 1 NEW INSTALLATION: \ t ` if�permitted if sewer is available within 200 Te (Noseptic tank or seepage,pet,] l PACKAGE TREATMENT k r j ]p SEPTIC TANK Ypz .t. ��- ----------------------------------- --Liquid Depth._-- ' ' ~ . ------------ Capacity ___.___ Ca acit ,._____` fT e _: Material - ' Size No. Compartments ------- ------------------- 1- , Distance to nearest•_Well......._______ Eoundat.ion,.i_ --- - ------------ „ j ----=--=---------- Prop. Line NG LINE: [ ] No. of Lines________ ______;_____-____..Lendth o e ca h-l.ine------------------_ _____=____-TotaI Length.__.____________--_______ A HI _ _ ¢) 'D' Box___ '_Type Filter Material•), ._------------ Depth-,Filter Mater-160,__ _ 1¢3 = Distance;to nearest: Well __---- _. Foundation `---------i----'--.Property E SEEPAGE PIT j ] Depth____ ___ ------ _.=__Number________-------:__ -_4_ Rock Filled Yes ❑ No -- Water Table;Depth =�° --- . - -.----Rock "Size ------ ----------------------- _ - -- --- Ro k S' a '�A_ Distance to nedresf:f11Va11 ' .-- -Foundation_.__..____----- -•-- Prop. Line--------------- REPAIR ADDITION Prev. Sanitation Permit#: :___.:.:_ -::- _-Date__ __'___: _3---------------- ) Septic Tank (Specify'Requirements)----------- -------=--==-=----=- _ = _ h ---------------- Disposal Field(Specify Requirements)__, - --------------------------------1 _ ------ - -- ------•-------------------- ---------------- --------- -------- ---- ---=----- =------ -------- ------------ - r �- if.. = - .-.--.------------------------------- ----- --------------- ---------- - -✓�. � � a - g q --- -�--� -------_------------------------------ ---- (Draw existing and 'required additi o everse. de) I hereby certify that I have prepared this application and that-the work wi be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations_ of the San_ Joaquin Local Health.-Witrid. 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 Com nsaition .laws of California.” pp Signed------- -------------------------------- OVvner I By :-�f other th n: - - Title__ c 1 k y ( a owner) f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- ` = ._ DATE...._ �j�.° f DIVISION OF LAND NUMBER: - - ---------------- -== -------y-.-----.=-::-:--:----•:------------- . DATE - ?__ ,:.--------------- ADDITIONALCOMMENTS. - ---------------=------------ ------•-------•-----=--------------------------------•------•-------------------- --- --- $: i ----- t ---------------- ---------- --------------------------- - = r Y Final Inspection by::`---==- _=' = = " - Date = ------ EH 13 24 SAN JOA UIN LOCAL HEALTH DISTRICT M 21677 REV. 7/76 3M