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�r`FOR. OFFICE USE: ;6 FOR OFFICE USE: APPLICAT16N FOR SANITATION PERMIT s 5/ {Complete in Triplicate} Permit o ------------- Date IssusdCA.-:/ --'".-��.. ..................................... ...... 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 Cou O inance No. 49 and existing Rules and Regulations: JOB ADDRESS/LOG N.4__,l.li7.._ ,..L..... ------.CENSUS TRACT-------------------------------- Owner's Name . .. --------- .....Phone�� .f-� Address------ - City.,." . Zip Contractor's Name---.------ - �(�[.<- _. .... .....License #------------------- Phone#to9/-(007..... Installation will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other........ ------------ Number of living unitsj_ ---_.__Number of bedrooms.--=3 Garbage Grinder--.7.__Lot Size. �� '^'`"� - Water Supply: Public System and name-- - -- ---------- ---------------------- ------------------_-.---Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay A Peat ❑ Sandy Loam [Q Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Materiat . 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,] t PACKAGE TREATMENT [ j SEPTIC TANK Size _ -. ------. --- -- -Liquid Depth.�..�-------- ----- Ca acit X Materia .. . -. . p No. Com artments_- "___.._..._ - p Y��a TYp .._ ._� y .� �..- - ---� Distance to nearest: Well............:�o .......Foundation.- � ------.- Prop, Lrin�e.. _.-......----IN] LEACHING LINE No. of Lines . . s...............Length of each line .... �---------- Total Length _ f--/.. _.....--. --..-------Oki 'D"B6-9-CCHH-Type Filter Material-1.5-�IkCj- Depth Filter Matyiai...f��i ._..._---------------- ----------- r Distance to nearest: Well.., ............ ..Foundat' n- .-.---_--.----Property Line._��.-. ----- .----------•.. i "3 1/ SEEPAGE PIT Depth.��d. . .._Diameter _ Number_..._ _ _..__...... t1 Rock Filled YesX No Water Table Depth-------16------------- ---------------Rock Size_ - ------------------ Distance to nearest: Well------/..C ..... ............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 becomebi ct to Workman's (ompe sati laws of alifornia." Signed..---- ... ,.._.. . Owner By------------- s Title.--- -- ------ --- ------- ..-------- - -------- ...... [ other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.................. *- .... - -DATE ...... /Y/7 7-- ...... . DIVISION OF LAND NUMBER......... ..... ............. . .............DATE........ ADDITIONAL COMMENTS.... ............. ......__. -. ......... - . ........ .. . _. -- Final knsgectlon b � .......... -- a e ------�— EH 13 24 SAN JOAQUIN LOCAL HEALTH D1STR€CT F&s 21677 REV. 7/76 3M