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FOR OFFICE USE: FOR OFFICE USE: �4PPLICATION FOR SANITATION PERMIT `'� (Complete in Triplicate) Permit No-. -------- ----------•-------------------- ------------ ------------ This Permit Expires 1 Year From Date Issued Date Issued_.... ..-_-.- ,pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION- / . � + 'GU CENSUS TRACT _--..- -- ----- . -- .. )wner's Name...----- Qom.- C ag �-.ZZs -------------_.Phone��?_7 Z Z� Address--------- -- -----------,3- ----=--- Y-- �" "�- --Z' � y- - _ Cit - Q -ontractor's Name------------ ---------- - --- - -- . .. - License # - -= -ZTI --Phone-.4 _--_`�G Q 7 .,.istallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- . . - - Jumber of living units:-.---)---------Number of bedrooms..-3-----Garbage Grinder------------Lot Size---------_ '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.) 1EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ..PACKAGE TREATMENT SEPTIC TANK S ec Liquid Depth( SSL'� - ------ -- Capacity_/aw TYPe.__g-...- Material- .No. Compartments -- ��-- ---- ----------- Distance to nearest: Well-------- v_ ..............Foundation......l..0. ......... Prop. Line LEACHING LINE (�, No. of Lines.--____3-............._.Length of each line._-._----------------_------Total Length_-._� 'D' Box--- Filter Material._ .._ .. - - ..Depth Filter Material---------A----.-._..-_------------------------------------ /� r, Distance to nearest: Well_.___,�v._.t____-.Foundation..--...�Q-.�"�'-___.--Property Line...s_ - - ----------------- 't SEEPAGE PIT Depth..z�.-----Diameter- 3�___.._.._Number �-- -___-. Rock Filled Yes No❑\,, Water Table Depth - - - - Rock Size-= xi1 - - `V Distance to nearest: Well -------- _._..............Foundation. Prop. Line------._-__--.-------..- "EPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date ------- - -.-------_-- - - - ------- --) Ptic Tank (Specify Requirements)----------------------- .... ---_- ------------- ------------ - - Disposal Field (Specify Requirements)------------ ------ ------------------- ---------- ------------ -- -- --- - --- --- ------------------------------ -- --------------------------------------- -------------------- --- ---------- -------------------------------- ----------------- _)- ------ ---- ---- --------------- -------------------------------------- ---------------_---------- ----------- ----------- ------ ---------------------- -- ------- -------------..------ ------ _------ ------ (Draw existing and required addition on reverse side) 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, 1 shall not employ any person in such manner as .w become subject to Workman's Compensation laws of California.— Signed---- alifornia."Signed---- ------ ------------ - ------ -..Owner y--------------- ...... -. ...- _...Title - - - f other than owner) FOR DEPARTMENT USE ONLY _,PPLICATION ACCEPTED BY__ _ .. 7-- 7-.-" -- - - - - _ _- -DATE -�.--, DIVISION OF LAND NUMBER__----- ----------- -------- -- ---------- ---------------- -DATE...------.._..--- --- - ADDITIONAL COMMENTS---------------------------------------------- ---- ------------ ------------- -- ---------- ------ - ------------------------------------------ ---------------------------------------- ------------------------- --------- --------- --------- ----------_------------ -- ----- ....... ---------------------------- ---------------------- ------ ---------- ---------- -------------- ------------------------------------- ----------- ------------------------- --- ------ ---------------------------------- ----- - --- -- ---- -- - --------------------------- inal Inspection by:-------- -- -- / -- --------- — / Date - --w�--t -------- �.` 'M 13 24 SAN JOAQUIN OCAL HEALTH DISTRICT Fas 21677 REV. 7/76 3M