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r = FOR OFFICE USE: FOR OFFICE USE: APPLI'CATIONFOR SANITATION PERMIT --------------------- (Complete in Triplicate) Permit No. . . -------- ....... .... This Permit Expires 1 Year From Date Issued Date Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, I This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: t JOB ADDRESS/LOCATI N:..... .. _ .. -.... - . . . . ------ -- ----------------.--.CENSUS TRACT-•-----•-•............... . Owner's. Name .. ............... ------ Address... ---. O .L.C/ . - City Zip-",C .-- ; . Contractor's Name..... --•..... ......:.......... License # ........ Phone-- --- ---- s f Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other -: ------ Number of living units:..... __--Number of br ms . Garbage Grinder------------Lot Size--... kWater Supply: Public System and name-- ........... ... .----------:.--------Private ❑ f --......--- Character of sail to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam E] Clay Loam <57 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,) R PACKAGE TREATMENT [ ] SEPTIC T NK [ ] Size -- ----------------------------- •-----------•--....._._Liquid Depth-------------..-----.--- - a : Capacity/ v�!....---Type ...Material..........................No. Compartments------ --------- T Distance to nearest: Well----..-- ........ ....:....-----Foundation..:- ....... ..Prop. Line--. _.__..�.... 4-- LEACHING-LINE .... `�� -y4rf�0 [ '] ; No. of Lines .... . Length of each I' e..----- .. ---�-. - --..... otal Lengthl -. ' Q' Box----_+-0....Type Filter Material � ...Depth Filter Materi ...... ....... Distance to nearest: Well - -------- Foundation..../�.........Property SEEPAGE PIT [ ] Depth.- --Diamet Number.---..-11,..-f................. Rock Filled Yes No Water Table Depth------------------------------------ ................-----Rock Size....... ..: ........................ Distance to nearest: Well------------------- ------------Foundation—-.---.-._.--- Prop. Line......-.--.-.--. -..----. REPAIR/ADDITION (Prev. Sanitation Permit#.._....-..:_:._._............... ..............Date.-------:----...._..................---..-.---} Septic Tank (Specify Requirements)........... # -----------•--- Disposa! Field (Specify Requirements[.... --------------- ...................... --- -------- - .... V Y, ............ . ``- [Draw existing and required addition ori reverse side) 1 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;1 shall not employ any person in such manner s to become subpggict to Wo 's Compensati Is of all rBY-------- ------- ............ ----------- ----.------....- ----- .-..... ,Title.- ' ' ,(If other than owner) ' FQR DEFYARTMENT USE ONLY APPLICATION ACCEPTED BY- -- ------=--------DATE ... . ..7_$-... = ... DIVISION OF LAND NUMBER.-- ----.. --- ..- .`'+... --- DATE...... ............ .. . ............. ...--- --... .....I _ .. ADDITIONAL COMMENTS. ----... ....- == ..--------- ................... ........................ -- ---- -------- r` ------ . ....- ------- ----- --- V ............ .......... ..............................................-- ....._.. ... _ Final lnspeetkon b .f_.2 ..7.g. Y /l ..Date.------ Ex is 24 S N JOAQUIN LOCAL HEALTH DISTRICT Fps 21677 REV. 7176 sen 9