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FOR OFFICE U E: FOR OFFICE USE: 3.--av, � APPLICATION FOR SANITATION PERMIT ' -------I Permit No-72-3 S"? [Complete in Triplicate) y------------------------------------------------------ -- _ -Dat!?-fssoed.- -.. -- -------------------- ------- -----I--------------- ----------_------------------------------_--___-..--.__ 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 a d existing Rules and Regulations: - ,. JOB ADDRESS/LOCATION---- ------------------- -- -- -- ----CENSUS TRACT.----/ti5 -------------- Owner's Name---- - --------- -- ---- - G_ �> ---------- Phone----------- ------------------------------------------------ ---------- i Address s - `'s -------- - ---------- -- -- - - City ..-.-..- - T� Zip Contractor's Name----- -- ----------- - -- -----------License ...Phone---,-12--W.9 Installation will soave: Residence' Apartment House.❑ Commercial E] Trailer Court E] f Motel ❑- f- Other ------------------------------------------ � l !� Number of living units:----- --____Number of bedrooms-----P---Garbage Grinder/110..l-ot Size.--- ------- Water ---;--Water Supply: Public System and name--- --------------------------- ------------------------------------------------------------------------------- --------Private Character of soil to a depth of 3 feet: Sand Silt E] Clay E] Peat ❑ Sandy Loam El Clay Loam E]E]Hardpan Adob Fill Material-- -.-------If yes, type------_----t------------------- (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,) s J PACKAGE TREATMENT [ ] SEPTIC TANK t ] Size--------------------/--�--------------____ _____________-__Liquid Depth.- - . Capacity-/�6-Q----Type -_Mater ial----&_�_ Cqa-101 _No. Compartments—_;? ---------------------- .—Distance to clearest: Well------ 49------_------------- ----Foundation.___- 10-_---.__---Prop. Line---- ,- LEACHING LINE [ ] No, of Lines--------- 2—_._Length of each line._._____7Z__-----------.Total Length.-------1 ---------------------- 'D' Box_____ . __Type Filter Material----41 �,..:---.Depth Filter Material------'--f --------------------------------------------------;C .Distance to nearest: Well---14-_,- -------------Foundation-----&-----------------Property Line------S�~---------------------- 99"Ac.-r- 11 [ ] Depth----------------Diameter------ ---------1__N,umber-------------------------------- ------ -1__Number-------------------------------- Rock Filled Yes ❑ No Water Table Depth------------------------r------- --•------ --------_Rock"Size----------------- - - ------------------------------ Distance to nearest: Well------------------- -----------------------Foundation.-_-----------------------Prop. Line--------------------------�00 REPAIR/ADDITION (Prev. Sanitation Permit#---------------_--------------.------------------Date------------__--- ) Septic Tank (Specify Requirements)------- ---------- ----- -------------------- ---------- �''--------------------------------------------------------------------------------------- Disposal Field (Specify Requirements)__________________ _ ------- ------------------------.------------------. (Draw existing and required addition on reverse side) hereby certify that 1 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 subject to Workman's Compensation laws of California." Signed --- --------------------- --- - - - --- ------ ---------------------------------Owner /J e By------y/�-"241 ----- -- - --------------------------------- Title---CG.'I�i�1��./17Z-- (If other than owne F R DEPARTMEIV USE ONLY APPLICATION ACCEPTED BY---- --------------------------------DATE ----------- DIVISION OF LAND NUMBER-------------- ----------------------- DATE ADDITIONALCOMMENTS---------------------------------------------------------------------------- ------------------------------------------------------------- ---------------- ----- --------------------------------------- - ------------ ---- ---------------------------------------------------------------- --- _---- ------------------------------------- ,,,,/� _ ------- - - ----- -------- ------------------------------------ ----------------------- ----- Final inspection by:------------- --- - --- --- ---------------- --Date ---------------------------- -- - EH 13 24 S JOAQUIN LOCAL HEALTH DISTRICT FaS 21677 REV. 7/76 3M