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F ,:FOR OFFICE USE: FOR OFFICE USE:- APPLICATION FOR SANITATION PERMIT. I ----------- - Permit'hlo,- (Complete in Triplicate) : / - ---- ---- - - -- ------ L. Date lssued.. -!_- . .--.--.-. .. This Permit Expires 1 Year From Date Issued a� 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 Rut and Regulations: ] !OB ADDO --. ---CENSUS TRACT..'...--- ,.." _ 7�. Owner's Name .: ....................... ---- ••-- --- -- -Phone------------------------------- r _ Address: . J ..... City � ZAP ��ryry y--j-- Contractor's Name................ --- License #-, D/„/1... Phone. 71 .......... Installation will serve: Residence Apartment F�ouse ❑ Commercial❑ Trailer Court ❑ . i Motel ❑ Other....- ... Number of living units:.........---..Numb. er ofbedrooms. _ - Garbage Grinder --- _..Lot Size....... D,�- -- Water Supply: Public System and name:. . ............. --------------- ---------------- ---- ------.Private Character.of sail to a depth of 3 feet:,: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loorn ❑ Clay Loam ?`� -Hardpan ❑ Adobe ❑ ' Fill Material.- .... ..-.If yes, type-._.__-...........-........... - — IPlot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reve.rse.side.] ` NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ... . _ /[ --- -- ------ --- - ------- --- ----- i ( ] SEPTIC TANK . ( ] Size .-..... jLiquid Depth PACKAGE .- No.`Com artments__-- e.q Capacity.. . . .�-4�-Type P �* :�' Distance to nearest: Well....... .... ..��.- . - - - --..-Foundation---1-Q -...,.Prop. Line----.-.-�..._ LEACHING LINE [ ] -No. of. Lines ...'�.�-------------_-.Length of each line 771? ..-----:._.._..Total L�erygth ..,...' _.._..- D' Box Type Filter Material...._j.1. Depth Filter Material.../17..,.---- ---------------- ------ .. .. �f� • ,, Distance•to nearest: Well--------------------------- Foundation--------------------........Property Line---------.............._ -- ----- SEEPAGE PIT ^Diameter--- --- -- - ---Number---- -------------------�- Rock Filled Yes 1 [ ] Depth. Water Table Depth.._...---------• ---,-e----------- ........ ------Rock Size..... ---..._......... . - ----- Distance to nearest: Well..:-..�..�~C,t-------................Foundation........................-.Prop. Line---------.------....... . .. REPAIR/ADDITION (Prev. Sanitation`Permit#----------------------------° ...............Date--------------------- -.---) 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 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........... ...... ..... .......... :..-:.. /If of er than owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...- DATE .-s �.' z°0..... DIVISION OF LAND NUMBE --------- �....� DAT 1 ADDITIONAL COMMENTS- ---- --- ------------------ ...... w.� 0�,z.. :� ...... ....: .. !. -----------•----------- -------------- -- - Final Inspection by: --- .- -- --- ------------------------- ----------- --Date-_.J.� 1 '.... i ... EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fss 21677 Rev. 7/75 3M