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FOR OFFICE USE: 'APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: --------------------------------------------------- -- (Complete in Triplicate) Permit No';r-83__ _.___ ---------------- --------------------------- -------------- This Permit Expires 1 Year From Date Issued Date lssued__�:�$7?� 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 Ordinance No. 549 and existing Rules and Regulations: B ADDRESS/LOCATION----- I!SOS L.�1_eSr_ Ql- -r -----v-----------------------------CENSUS TRACT.--- -------- ---------------- - wner's Name. . � ll� .CD�_ .--� --- - Phone._ . .J_ �� Address L d '�`a -C - �f- L�L°-� City �5 Zip .-"-" Cahtractor's Name------- •r-�a.� License # �] Phone-------------------- -- in allation will serve: Residence e Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----- ------ --- ----- - - - ------ Number of living units: of bedrooms Garbege Grinder_. o _____.`/ _.� -= - .Lt Sized �� ___---- --- ---- Water Supply: Public System and name------------------ --------------------'' Private El- - ----------------------------- Character of soil to a depth of 3 feet. Sand ❑ Silt ❑ Clay-E] Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe2N.• -Fill'MateriaL_.---..-.._If yes, type----------___________.--.---.-- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if pub(;ic.sewer is available within 200 feet,] PACKAGE TREATMENT "` a' [ 1 SEPTIC TANK [ ] Size --------------- - ---T------ir.---------------------Liquid Depth.---------------------- -a 7 - .� `7 t Capacitya Type-----------------I----Material--------------------------No. Compartments-----------------------------------w Distance to nearest: Well------- s---------i----------------=----Foundation-------------- ------------Prop. Line----------------------- -- LEACHING LINE [ ] Na. of Lines---------------- ___________Length of each line.__._._' .---------------------Total Length---------------------------------------- 'D' ---_----.-_-----. __---'D' Box---,--------Type Filter Material--------------------Depth Filter Material-`---- -----------,---.--------------------------------------_. Distance to nearest: WeIL__ ___.____ .. _-�.:____Foundation___________________._'__-.Property Line----------------------------------- SEEPAGE PIT [ ] Depth----_- Diameter----------------_Number_-.-----_----------------------- = Rock Filled Yes ❑ No ❑ 0 �--�—� i 4 Water Table Depth - --- -----------r-----------------Rock $ize------------------------------------------------ Distance-tonearest:-WeH _ _: ---------------------------------Foundation------ -------------------Prop, Line.----.---------------------- .x REPAIR/ADDITION {Prey. Sanitation Permit#-..-----.--.`---------------- ------- Date------ Ptic Tank {Specify Requirements)--------------------------- ---- --------- -- ------- I------------------------ --------- Disposal Field {Specify Requirements)....CVQ4 ____ _ '_____ _ .Q-(v----,�„ - __-. '- r Y -----------------------------_---€---------------------------------------------------------------------- ---- ---------------------------------------------------t---___------------------------------------ ----------------------------- i I {Draw existing and required addition on reverse side) I hereby certify that 1 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: # lot- "I r"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 subje to War Compensation laws of Caliifornia.''j gned.- Owner � f BY s-- ----------- ----- ----.'Title --------------------------- -(If other-than owner) FOR-DEPART ENT'USE ONLY APPLICATION ACCEPTED BY--- -F IC DATE.---- - 7A/ ?5-------------------- _� DIV1SlON OF LAND NUMBER.. - DATE-.---------- +--- ------ ------------------------------------------------ ADDITIONALCOMMENTS-- ---- --------- -------------------------------------------------------- ---- ---- --- --- ---- -- --- -------------- -- ------- ----------------------------------- ------------------- ----------------------------------------------------------------------------------------- -- ------------------------------------- ----- ------ - ---------------------------------------------------------------- -------------- - Final Inspection by:---- - ----- .. E -- - --------------------------------------Date- --` � EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677REV. 7/76 3M