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FOR OFFICE USE: I I FOR OFFICE USE: ... APPLICATION FOR SANITATION PERMIT tea; - - (Complete in Triplicate) Permit No. - -- Date Issued. `'�� r.. -------- _ _ 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.//.e-,d--�?.. --- - -- --- _._. CENSUS TRACT....----------- Owner's Name ------------------------------- Phone ----- ------- --- ----- '-Address- - �at�.�... �' �" Cit - Zi Y - P--- --- ---------- ---- ----- Contractor's Name--- R...... .. :� �"--_,� ---- ._._License #-_1�� . .Phone._ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other- ---- - - ---------------- Number of living units:------ ____._Number of bedrooms__ __Garbage Grinder _ --- 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 Le Hardpan ❑ Adobe ❑ Fill Material.. __ _If yes, type----- ___..._..._.__.._._.__ r(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 see age pit permitted if public sewer is available within 200 feet,) _PACKAGE TREATMENT [ J SEPTIC TANK [f� Size- ' /f/ 4 - -----------------------Liquid Depth ---------- ---- - Capacity_.IZ'. ._._..Type -Material_. Compartments._-_.;�,._-----_-.._._.._..._� Distance to nearest: Well.______.._rx --_--___-_ Foundation._-_/'_ ._.____Prop. Line..__s1�_e__-_ —LEACHING LINE [►'� No. of Lines.....____j----- _------Length of each line......._ _ - _____Total Length _.. D' Box----- ------Type Filter Material___ _-S_R------Depth Filter Material-------/_P/^'___._ Distance to nearest: Wel L__ .�_�T..___.__Foundation____f__�_ — Property Line....r�_____ ______I [tK Depth_._ IZnma+ar�-_-XL----.Number_._...___. .__.._____.____ Rock Filled Yes No Water Table Depth------------- . t �---------------------------Rock Size.-----4./.2- --,--------------------------- Distance �� - - Distance to nearest: Well...._..._...�^:�'"_____________Foundation-------A._�----Prop. Line------ -- ----- REPAIR/ADDITION (Prev. Sanitation Permit#...................__-______________.__._Date____________________._____________....1 _Septic Tank (Specify Requirements)--------------- -------------------------- ------------------------------- --------------------------------- ---- - ------ - - ----------------Disposal Field (Specify Requirements)---- - -------------- - - -- -- ------------------------------- - - ----------------------- -------------- ---------------------- ------- -------- ----- --- ----------- -- ------- ----- ------------------ ------------ - ----- ---- -- -- ------- - ---------- ----------------- ---- - ---------------------- --- -- ---- ------------- ----- ----- ----- ---- ---- - - -------- - --------------- ---- (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 thnt in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed------ ----- ----- _ ----- - �� - Owner �_ Title C BY ' � �19 - (If other than owner) FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY---- - - - ---------- -----------_---------------DATE I DIVISION OF LAND NUMBER ---------- ------------------------- --------------------------- ---- ADDITIONAL --ADDITIONAL COMMENTS-- ---- -- ------ -------------------------- - - - - - -------- ------------ ------- -- - ---------- -------------------------------------- --------------------- --- - ------------------- ---------------------------------------------------------- ------------------ ------- _- -- - ---- ---------- - --------------------------- ------------------ -- --- ---------- ---- ----- -------------- --- ---------------- -------- ---------------------- ---------- -------- ---- / ---- - --------------- ' �j Final Inspection by:.. - - - VOAQUIN Date..--- ... EH 13 24 SAN L CAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M