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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------'------------------------------------ -- �' 3 (Complete in Triplicate) Permit No ------------- --------------- AM - i 7 . Date Issued-- -------------------- ssued__ - _ This Permit Expires 1 Year From Dkpte 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 - ' JOB ADDRESS/LOCATION � _ -_-------- - ---- - ---------.- ' ---- -------- .CENSUS TRACT_4; _ - --- Owner's Name. � _ '--- ---- --- -- Phone . _ { _ - Address = '°1 � --- City---_-- #',. � ZiP Contractor's Name.. - - �--�`r�---- ---" ------------- ----- i_License #- - •;��. f Phone---.— --: '. -- ---------� Installation:will serve: Residence , Apartment House.❑ Commercial ❑ Trailer Court ❑ ` N1:�tel ❑ , : Other-- --=------------------------------------------ Number ----- ---- o. -- '= Number of livinunits: Number.ofbed ooms --_ _.Garbo e Grinder Size---- _ ---d----------------------- 9 � Water Supply: Public System and name-- --------` ----------------- --• -- ------.Private r - _ - Character of soil to a depth of 3 feet: . Sand 0 :Silt Clay ❑ . Peat ' Lndy Loam ❑ Clay Loam ❑ k Nar pan ❑ ' Adobe ll Ulaterial------------If yes, tyke -------------- Q1 (Plot plan, showing size of loin, location of system;inyrelation to wells, buildings etc. must be placed on reverse side.) NEW INSTALLATION.:— (No 'septic tank or seepage. eep g p t pe mitted if public se er is available within 200 feet,) TREATMENT [ ] 'SEPTIC-TANK '[1] `" Sizes-----------------`--__-- -------------------------------- PACKAGE - -liquid Depth------------------------- + Capacity--=----------"-------Type----- = Material' =---- -----=' k=No. Compartments-------------------------------- Distance to nearest: Well�� _: oundatian--_._..________________Prop. Line________;___-----------_ LEACHING LINE` [._] No. tf Lines__._ __:_ _ .Length of each li e ____" r __.Total_Length --------------------- ------------ -D' ____-__-- _'D' Fox------------T pe Filter Material__.__- ----- ----Dep h Filter Material-----------•-------,------------ r `.�.... -- q - ---------------------- ----------------------- --- -------- __..----------------------- ------Distanceto nearest: We!I - - -----------•Foundati n------------------------.--"Property Line -- ' SEEPAGE PIT [ ] t De p _.Diameter . ..R ____Number_____________ ------__------- Rock Filled Yes ❑ No ❑ jWater Table Depth1--------------------------------------------------.---.Rock Size-------- ----------------- -- ---- ----------- ,t w fes,: � � Distdnce:to nearest W_jell_ _ __ -._Foundation ---------------..Prop. Line -.- ..---------- REPAIR/ADDITION _-._-_ : .. t ' REPAIR/ADDITION"•(Prev. Soni ati n,,P�ermit� ._`-_ Date-_-.___� ------------------ I ) Septic Tank (Specify Rec�u"irements --- ----- ------- ------------ --- -------- Qisposal Fi ld (Specify Requirements). .-: Q c � -------------- ------- ------------------------------- S ------- --- ---f�------------- ---- - ^� , : �------------ _ --------------------------------------------- ----- :: ---------- i� [Draw existing and required additionon*re erse 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 that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as to become subject to Workman's Compensation'lows of California." r _ k Signed ----- ----- - -- : Owner B - - =---------------------'-- - Tirle - -------------- - - i (If other than owner) i OR DEPARTMENT USE ONLY'` APPLICATION-ACCEPTED BY_` IZ - ----------- �. -DATE.-�---�._._:.'--- - DIVISION OF LAND NUMBER; - :: -----------------DATE,-.---- ------------- . ._. ADDITIONALCOMMENTS---J'--- ---- -----•------ ------------- ------------------- ------------ - ---•---------------- -- --------- ................................- _.... - � --- - ---- ------------------------------ --------------- ------------------------------------------------ ------------------ -------------------------------------------------------=-------- --------------------------------------------------,-------------------------- ----------------------- Final Inspection b / =_Date. _._ ------------ _____-_--- eN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT gas 21677 Rev.7/76 3M