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FOR OFFICE USE: �� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------- (Complete in Triplicate) Permit No._ S_.�_lv..-�_7 ---------------------=------ ----------------- /5", Date Issued-- '_:1 -_78� -----------------------------------_._______.___.._._.__ This Permit Expires 1 Year From Date Issued + �j1 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/L TION--- - ,: _ n L«L J - - -CENSUS TRACT. (/ Owner's Name_—wutAI�. -.. _1 -fir '�?.--------------------- ----------------------------------------------------------.Phone__ _/_ �---W_ Address e.� — ------ -- --- City Zip -- --------------- Contractor's Name___ ,,v .�c,- -_' _j�'. K- _�---------------------License # ----Phone- r , Installation will serve: Residence ®Apartment House. Commercial ❑ Trailer Court ❑ r r Motel ❑ Other----- -- - -------------------- ---------------- Number of living units:_._.,-{_'.------Number of bedrooms_.�___Garbage Grinder-.----------Lot Size-------- ----------------______..____- Water Supply: Public System and name------- . - -------------------------------------- ------------ -----------------------------------------Private [ w Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Ej__ i 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,) F Qn PACKAGE TREATMENT [ ]' SEPTIC TANK ----------Liquid Depth.-_.--.---_--_-----_._ �1 [ � Size-------------------------------------------------- Capacity--------------------:TYPe-- ---------------=--.Material--------------------------No. Compartments----------------------------------w r • Distance to nearest:.Well._..____. -------------------------------Foundation--------------_-----------Prop. Line------------------------- - �1 LEACHING LINE [ ] No.. of Lines------------- ---___.-..Length of each lina-------------------------------Total Length _. ____,,•_--------------------------- 'D' _._-_---___-.----------- D' Box--------- ---Type Filter Material--------------------Depth Filter Material------------------------------------------------------------_N Distanceto nearest: Well---------------------------Foundation----.-----------------------Property Line-----------------------.------" SEEPAGE PIT [ ] Depth------------------- - � Diameter--=-----------------Number---_----------------------__-_-- Rock Filled Yes ❑ No ❑ Water Table Depth----------=--------------------:-------------------------Rock Size ----------------------------------- Distance to nearest: Well-----------------------------------------------Foundation-- -------- ----_----------Prop. Line------------------------ REPAIR/ADDITION _._____-______._REPAIR/ADDITION (Prev. Sanitation Permit#----------------------------------------------------Date---------------------------------------------_] , SepticTank (Specify Requirements[. ---=---------------------- ---------------------------------------- ------------------------------------------------------ Disposal Field (Specify Requirements) ��-------------- - ----- ` --`-------- -----..1- 044;A-- ------------------------------ A. --------------��------- f d , ------- ------3- -------��-_--------- ---- -------------------------- --------- -------- (Draw existing and required addition on reverse side) ., I hereby certify that I have preparedthis application and that the .work will be done in accordance with San Joaquin County Ordinances, State Laws, an ies and Regulations of the' San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: i F "I certify'that in theperF,ormixn of"t ie work for-which-Th-is permif.is;issued, I shall not employ any person in such manner as to become subje ,Woi^k. s'Ciipen as tion.,,laws .of California." Signed .r:- -�a, ------------Owner BY- I----= - ---------- Title l � i i (if other thanlowner) -- FOR)DEPARTMENT USE„ONLY APPLICATION ACCEPTED- BY_'_ - `.:�, ------DATE.-- g— = ------- �. ------ - --- ---- - ---- --- ----------------- ---- ---- DIVISION OF LAND NUMBER ] } -'#"': =' --DATE------------------------------------------------ s _ ADDITIONAL COMMENTS- ------------------------------------ ---- --------------------------------- -- - ------------------------------------------ ---------- --- _---___---_--.-__-_____-____._____--_.__-___________--__.-------- � - f `-------_---..--__-.-._-__-_-___-__._--__________--._.-----_-___. ---------------------'----------- �T� -----------___-_._______________. _ Final Inspection by:-- --- ----n---'=- _' "”„ Date ----------- --- 4 /r EH 13 24 SAN AQUIN LOCAL HEALTH 61.STRI,CT / F85 21677 REV. 7/76 3M