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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �� 5—� ---------------------------------- (Complete in Triplicate) Permit No-------_----.-......... �ri3" 7� Date Issued..... .............. ------------ ---.---- ------ -------------- This Permit Expires 1 Year Frbril.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/LO ION. - - ----l�' .�C1�Sca ------- - CENSUS TRACT------- -- J L `` ecs - 3 Owner's Name -- �� -----------C..�C�S.--t'!?ft�----- ----- ------------------•----------- ------------ Phone 3��1� AddressQ�' NO 9F�(-.-`---- ---------City- --- Co - Zi -------------- - - - Contractor's Name- dyr------ � ..�=5;—A-------------------------License #-5a--574t�--------Phone----- �1640E-__• ._ Installation will serve: Residence R1 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------ --------------------- Number of living un -_Number of bedrooms-->-3----Garbage Grinder-_14-----Lot Size-----_--�`�__----«-- --------------------------- Water Supply: Public System and name----- ------ ---------- ---- ------------------------------------------------------------------------------------------------------Private zr 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK �- ----------- Capacity- 1j [lj� y�� Size '� `r/�, r�rz' Liquid Depth.--- ----------- y Capacity-1.2S------Type.--_-(1t__------Material-_-.l_`_.��'`------.No. Compartments--------- -------------------- Distance to nearest: Well_-----7U-------------------------------Foundation ------------Prop. Line_!_- LEACHING LINE [ rY No. of Lines ------ -3-----------------Length of each lin e----- -------------Total Length..__�a.C:,-l------------------ D' Box__�Y_ -Type Filter Material-I .�-f-{,Depth Filter Material____a___________-------------------------------------------- Distance ____*__.___-_.____._________---.--___-.--.Distance to nearest; Well------ 4 -------------Foundation-------- -----_--_.Property Line-----116----------------- SEEPAGE PIT Depth.__ .---.Diameter._3.+3 .........Number------_ _____________________ Rock Filled Yes [x]/ No Water Table Depth------ d--r---- Rock Size- -7�- �� /� ♦ E + Distance to nearest: Well--------------_---.____--_----.._____---Foundation...--. �---------Prop. Line----��___._--___. REPAIR/ADDITION {Prey. Sanitation Permit#---------------------------------------------------Date-------- ------------ _--------------_1 y, Septic Tank {Specify Requirements)------------------ - =' Disposal Field (Specify Requirements)-------------------- - - - -t--_...-_-_ -� •'� " J - ------------------------ ---------------_------------------`-----'---------------------- r.-_...----"--------- if. ------------- ------------------------------- �+. (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: n "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 By-------- ----------------Title---+00i�1------ ---��C {I other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- - ----------------------------------DATEF : �~ r -------- - DIVISION OF LAND NUMBER - - --------------------- -----------------DATE.--------------------------- -------------- -- ------------------------------------------- ADDITIONAL COMMENTS--- ----- --------- - ----------------------------- ----------------------------------------------------------------------------.. --- -----------------------------------------------•------------- -----------------•----•---------------------------------------------------- -------------------------------- --------- Final Inspection b .------ -- ------Date----74! 11--.-7 5r EH 13 24 SAN JOAQUIN LOC,o(L HEALTH DISTRICT F&S 21677 REV. 7/76 3M