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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------- No.-., 71-2-2,C (Complete in Triplicate) it No... ............. ..... -------------------------------------------------------- Date Issued__S--.//__/-7F --.-.__.____------------ -------- --- - 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 and existing Rules and Regulations: JOB ADDRESS/LOCATION- --�� e ----- CENSUS TRACT-------------------------------- ---- --- Owner's Name [ --- 'Gz- a-1 ------------------- -------- --- -- ----- Phone.------------------------------------- Address----------------- .� � --------- City - r Zip -----�� License #___3z__�-_-__ Contractor's Name------ �.__- ._ �d' .....�: Phone---------------------------------- Installation will serve: Residence [L( Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------ I-------------------------- Number of living units----------- --_Number of bedrooms__:_---Garbage Grinder__ -------Lot Size______________________ _ _ ___ - ------ Water Supply. Public System and name--------------- - --------- --- --------- --- ------ -------------- --------------- - ----- --------------------------------- Private Character of soil to a depth of 3 feet: /Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan X 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 [ Size___��_� __h_�_. -------------------Liquid Depth__ ___-.---.._--__-_ Capacity.-(.L.Q'd--------Type-- --___--- _-,Material---- ......No. Compartments-------- -------- Distance to nearest: WeIL___________s -_--_- --Foundati --------------n _f-------Prop. Line----(-,/.............. -__- LEACHING LINE [ No, of Lines-----------_-_----------------Length of each'-WF!e—____74'§-_ ---------Total Length ---.J--- ----------------------- i - D' Box-----1-----Type Filter Material-_--__-- ---.Depth Filter Material----- l -X-_-3-------------------------------------- - Distance to nearest.-Well-_---.-y L)_1:1--------Foundation-----1__O._ _. t__.____Property Line------ /---?_------------------ SEEPAGE PIT [14 Depth----!-Y Diameter.-.-.3_'3..`.'_-[umber..__.,_._____. Rock Filled Yes [�- No Water Table Depth--------------- --------------------------------------Rock Size------- P------'Y -------------- Distance to nearest: Well-----------------1 0 Q__ . Foundation---------1 p --.Prop, Line.----�- --__-. REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------.=-___.___-__________.Dater y'-"----- _------ ----- --------- ------) SepticTank (Specify Requirements)------------------------------------------------------------------------------------------ ----------------------------------------------- ------- ------ Disposal Field (Specify Requirements)-------------------- - ---------------------------------------- - ---------------------- ------------------------------------- d ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---- ------ -- ------------------------- -------- --- ----------------- ------------------------ ----- - (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 r 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 �L By----------------------------------- --------- - 04! ` -�1� �— Title 'r4 (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY � f� DATE DIVISION OF LAND NUMBER.--------------------- -- ------------------------DATE----------------- -- -------------- ----------------------------------- ADDITIONALCOMMENTS---------------------------------------------------------------------------------------------------------------------------------------- ------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ -------------------------------------- -------------- ---- --- � ------ -- � peFinal Inspection by=--.--- EH 13 245 21677 REV. 7/76 3M SAN JO UIN LOCAL HEAg DISTRICT J