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FOR OFFICE USE: T � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- ------------------------------------- - (Complete in Triplicate} Permit No._________ --------------------------------------------------------- S 3a-7� Date Issued__._.�___._..___.- 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION....- -----r 19_ _4 Ff.a -' _T- ---------------------------------------CENSUS TRACT---------------- --- - --------- Owner's Name.---60.#1 rs----------------------- ---------------------- --- -------------------- ------------ Phone-------------------------------------- Address..... ------------- -------------Address_.__. . -- -_2k+ ' T------------- ------ -- ---city------ '�+�-� - -- --------- -----Zip ------------ Contractor's Name- � �-----�'4_PE�P/�' ._t^/�' � -License #._-j_4'S'_34_Z___Phone_407�_P_�_ -4rll Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ .� Motel ❑ Other-------------------------- - Number of living units:__;___ -_,-_Number of bedrooms.___ __.Garbage Grinder____---_----Lot SizeIVOIJ-2.2 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 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 public sewer is available within 200 feet,} PACKAGE TREATMENT SEPTIC TANK b( Size____ --------------Liquid Depth._____� �-------------- ti U. Capacity--..0 a TYPe-----------------------Material -------------------------No. Compartments--------2----------- ----------- Distance to nearest: ! � ________________________Foundation------ Line______rof._____________. LEACHING LINE ji No. of Lines------------- --------------Length of each line-----------q0-------- _ Total Length ---�00- ----------------------- �C 'D',Box----+1-v-----Type Filter Mat erial---.1?0_c_'l_t'---Depth Filter Material--------/1-e--,---------------------------------- ------ Distanceto earest: Well___._/A'_011---------Foundation 0.............Property Line---------5------------------------- SEEPAGE PIT [ ] Depth._--------------Diameter----------- --------Number--------------------------_----- Rock Filled. Yes ❑ No ❑ Q Water Table Depth----------- ------ ---------------------------------------Rock Size------------------- ------------- r Distance to nearest: Well------- ----------------------------------Foundation.I__ Prop. Line REPAIR/ADDITION {Prey. Sanitation Permit#--------------------------`_---------------------Date------------;-----------_-.----------------.--) Septic Tank (Specify Requirements)------1-2-Q.- ---4'4_4_L.'s A-0----.---- ----•---------------_n.,�---------------------------------------------------------- --------- Disposal Field (Specify Requirements)--- '„ 3 , e ----- ------- ------------------------- � T _________________________`------------------------------.------------------------------------------------------------ ----------------------------------- __________________________________________________________________________________________•X-----1___.__.. 41 (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 sub' ct to Workman's Compensation laws of California." + Signed --------------- , Owner BY---------------------------------------------- ---------------------------------------------------------Title---- ----------------------------------------- - ----------- -------(If other than owner[ FOR DEPARTMENT USE ONLY, APPLICATION ACCEPTED BY -- ---- -T------------------- DATE. -p2_. _.`'_: . DIVISION OF LAND NUMBER-- --------------------------------------------------------------- --- DATE-------------- ---- ADDITIONALCOMMENTS------- ------------------------ ---------- ----------------- --------------------- ---- --------------------------------------------------- ----------- ----- --------------- ----------------------------- ------- - --------------------------------------- --------------- '- -----------------+-------------- ------ ---------- ------------ ------------------------------------------------------------�`- - ------------------------------- ------------------------------------- ----------------------- -------------------------- - --- -- ------------- --------- --- ------- -- ------- �---- --- -------- -------- Final Inspection b .___Date_- __.. ----------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M