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FOR OFFICE USE: 1 _ f FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT l J_ mak. Permit No.__� :. � (Complete in Triplicate) -------------------------------------------------- , f [ Date Issued :_ �-.<7k' ---------------------- ---------------- This Permit Expires 1 Year From Date Issued J Application is hereby made to the San J aquin Local Health District for a permit to construct and insta II the��rk herein described. This application is made in compliance County Ordinance No. 549 and existing Rules and Regulations: -, �'---------- CENSUS TRACT-------------------------- JOB ADDRESS/LOCATION-.__� __ �_ - Owner's Name ' - '-" - -- _ Phone. 3-'l�Z0 r - 1 - Address- --.:---- _ i o- --- -- -- i' C tY _ Zip- -- Contractor's Name " f- _ License # 9 0-:Phone �b-� 6 6 Installation',will serve: . ResidenceApartment House.❑ Commercial ❑ Trailer Court 1: ❑ , .. .o).... 4.....,.t. otel ❑ Other_ -----=.------------ ----- . _-+. ;. Number of living nits:_- - f(_--.Number of bedrooms°-_ ---_Garbage Grinder- ___ -Lot,Size_.-70_-..K-_r_..O--------------- . � Ott - Water Su --- pRI Y: Publit System and.name--___.._____.__ =- ------ -----_ s Private ❑ Character of soil fio a depth of 3 feetSand ❑' .=Silt❑ Clay ❑--Peat❑ Sandy Loam ;Clay Loam tY, , Hardpan ❑Adobe❑ Fill Mater'ial.._ If yes, type-_-- f w (Plot plan, showing 'size of!lot, location'of system in relation to.wells, buildings, etc, must be-placed on reverse side.) i NEW INSTALLATIONc�(No,sepfic tank,or seepage;pit permitted if public sewer is available within 200 feet,) �--�•�;^�-.,sem ji ; I �' PACKAGE TREATMENT [ ]I SERTIC TANK."["] - Size------ --------------- --- -----` -----------------------Liquid Depth �. ' -- Depth. ------------ ------ -- -__-= - '{_ -- 1--=- = Type---- ------=-=- --'---Material--------------------- --No.- Compartments__`-------------------- Capacity,.- is ---Capacity, - isfiance.tonearest: Well-------- ------------_ Foundation------------: _ Prop. Line------:-----,'__ ,____-- ---------- LEACHING DZ LINE [ ] N-U f Lines'.:.:..: .. :. .'- ---- Length of each line------------------------------. . Total Length.--.-,--:.------------ ------------ e ii D' Box-..- Type Filter Material -.--- Depth Filter Material-.: --------_----E---- ---------------- ._ cI� D n : , 4•stunce:to nearest` Well ---------------- __ Foundation__ Property Line --------------i SEEPAGE 'PIT` [ ] be th -----Diameter_;------;------;----Number--------_--------------________ Rock Filled Yes ❑ No ❑ ate! Table Depth ' ' - -------------------------------------- ----- Rock Size---------------- ---- + + Distance to- eare§t: 1r1/ell---'---- '-------------=------ ---L Foundation__.---.--=-----_--------- Prop. Line----_--,------------ REPAIR/ADD.1TION_(P_rev.-San.itation'Permit _ -.-'- --------------- ---- -------'---:_j:_.Date---------------------- ' -::=------_-f----' 1 Septic Tank (Specify Requirements)--'-----'-- - --- �_ --_IAF.-- ?8,9 ! --- Q, h Disposal Field]Specify Requirements);_-----:'::---'---- ---- --------------------------------- ]--.------------------------ I } - -----' - ---------------------------------- -- -- -------------------------------------------------- - `` -• .► �:.,�; . L - ; -------- ----- ---- -- - -- --- - ------- -`------=------------- -- -------------------='- -------------==-----'------= -„-----'T - - - - ..p (Draw'existirig and required addition on reverlse side --- --- - hereby certify that l have prepared this application and that the work-will be done :in accordance-with San- Joaquin, County tY Ordinances, State Laws; and Rules.'and-Reg ulations-of-the--San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify that in the performance ofthe work for which this permit is issued, I shall riot employ any person in such manner as to become subject to. Workman's Compensation laws.of California.” w „ . # Signed----------------- ------ ------ -------- -- ---Owner A BY # �� - ------------------------------- 1t - (If other than'Lowner) Y - FOR DEPARTMENT USE ONLY , { APPLICATION ACCEPTED BY = - - ------ DATE. 5 - --- '-----------'-- DIVISION OF LAND NUMBER.-_ ----- = --- =' DATE-: - - ----:- ---------=------------ ADDITIONAL COMMENTS_-: -------------- --------------------------------------- ----- ----- -----=------=----------------•--------- ---- a--------------------------------- f Final..Inspection•'by:. .. _ -_ y ---- ---- -- ----"----=----= �"'------------------------------------=- fti EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M z