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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: l`_" (Complets in Triplicate) Permit No...-./ _- �Q ------------------- This Permit Expires 1 Year.From Date Issued Date Issued--- "_ 7 - Application is hereby made to the San Joaquin Local Hea th CSistrict for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549 and xisting Rules and Regulations: JOB ADDRESS/LOCATION/ __..- CENSUS TRACT -------------- O[, owner's Name- -- - - Phone , 7 2 "e -S7----------------------- _\ddress.- '' / ---- -- _city----- - ----- Zip ------------- -- ------ Contractor's Name --- . I •-- --- - - -------------License # Phone- -- --------------- nstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ...... - - Number of living units:_ .� --Number of bedrooms-,%-3-- Garbage GrinderlV4-__Lot Size-----/I__ 'C/�C',J Vater 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.------------------- ------- TPlot 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,) 'ACKAGE TREATMENT ( ] SEPTIC TANKSize.CKl,jjt [ ] K - Liquid Depth ---------- bo Capacity. -. -.---Type- . - - Material------------------- - --No. Compartments- ---------- -------- - ------49' Distance to nearest: Well ----- -- --------__- ---_--..-_-,Foundation__--___--_-_____ Prop. Line----------------------__ -EACHING LINE [ ] No. of Lines---------1-------__.. __ Length of each lin ._.____.._--_-Total Lewth --------- ......... -------- 1I D' Box_. .. _.. Type Filter Material-...L-_.----- - Depth Filter Material_ ----147 ---------------------------------________-� Distance to nearest:D ametelr -----------------_Numberundation - - -_.--_-_Property Line_. ._-..-.---_._-.._--.-__ SEEPAGE PIT ( ] Depth----- -- Rock Filled Yes ❑ No Water Table Depth - -------------------- ---------------.Rock Size - ------ ---------------- -- -------- M Distance to nearest: Well ----- _ ---------------- Foundation ------ __ Prop. Line REPAIR/ADDITION (Prev. Sanitation Permit#__.------,------- --------_----------------------Date-----_- -____ _ - ,eptic Tank (Specify Requirements)__ . _/!2_ • _•----_/-__--- Disposal Field (Specify Requirements)_C7� _-SLt_Zf _ � _ ---��-4g-- -_- ---- - _ -___- .- -- _- -... tt k ---- -------- ------- - ----- ------------------------I--------------------------------------------- -------------------------=-------------------------------------------- ------ - ------ (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, I shall not employ any person in such manner as o become subject to, Workman's Compensation I ws of California." Signed � L� �� ... - ---Owner 3y -------- --------------------------------- ------ -------------- ------ - --------- -,.Title. ---- - `f (If other than owner) F `DEPAP,TMENT USE ONLY %PPLICATION ACCEPTED BY------- ----------------------- -----------------------------DATE.- ------ -- IDIVISION OF LAND NUMBER.. -------------- -------------------------------------------- ------------------- -------.DATE - ADDITIONALCOMMENTS----------- ------------------------------- ------------•-----------------••---- -- --------------------------------------------------- ----------- ---•-------- ---------------------------------------------•------------ --------------------•-- --------------------------------•---------------------------------------•--------------------- ---- ------------------------- iia---------------------------------------------- -- ------- - - -----------•---------------------------•-----------•---------------------------------------------------------------------------------------- -----------------------------•------- - - - ------- -----------------------------------------------------------------•--------- --------- hA� ---------------------_------ =inal Inspection bY: Date S- �G ------ w.H 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M