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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7Pe OFFICE USE: - ----------- (Complete in Triplicate) o.� a --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued_ .=� "?, Application is hereby made to the San Joaquin Local-Health District for a per to construct and install the work herein described, r This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION._rw t t _ F _ ---------------- CEN ' Owner's Name_-- 1 /J _. - -_CENSUS TRACT ----- Address ---�3-0_ . hone__ - - -- -- i �- _ P - -- _ Contractor's Name. fi City_ _ --------------------- Residence Phone_ ___._-------------------- Installation- will serve: r-�-- �� - � •� _ _ _� . � _ License # ------ Apartment 'Ho"_ Commercial ❑ TTroiler Court.0`._.,�_� # Motel [] -'Other---- ------- -------------- ------------ Number of living units_ ________Number 6f.bedrooms_.C9 Garberge.Gr.inder___ ------_-Lot.Size---------_- ' ._. c r -- ------------- Water # Character Supply. so Utolla depth of 3�feet: Sand Silt ----------------------- "-Private Qr System ; ❑ .Clay [] Peat❑ Sandy Loam 0 Clay oam [] r Hardpan ❑ Adobe.0 Fill Material____ -_-__If est e__'_-1 (Plot plan, showing size of lot, location of system in relation to wells, buildings,letc.must be placed on reverse side.) ( I NEW INSTALLATION: (No;septic tank or'seepage :pit permitted if public sewer is available wiihiriJO0!feet) l PACKAGE TREATMENT-[ ] - SEPTIC TANK"' ' " - % .l [ l Size- -- 'pth-----------------------I Capacity:-:--------- `TYp?------ -----------=----Material-- No. Co partments: ------------- - - ------... ---------4------'Foundation--= '"�-Prop. .Line-i= •.,- �-fl LEACHING LINE ,� `~— 1q,I i [ a. . No. of Lines------ ------------ -=-- --.Length of each line,:---------_--_--------------_.To al Len th.------ f�! - - ' — ... ----- - - --, .- .. D' Box----- ----L-Type FilterMaterial--------------------Depth,Filter.Mater`iaf�-__---------- -.= Distance to nearest: Well - -___Foundation -Property'Y7 f, Ia SEEPAGE PIT "' Line--------------- Distance. -_; -- . ---., [ l Depth--- _-- -Diameter Number--- G t - -- - ! Yes ❑ No ❑ Rock-Filled # Water Table Dept = = Rock Size z P ---;----- E Distance.to nearest: -Nel_l.-' Foundatiot--------- ---------------Prop. Line_-- - e _- ---- -------------- ------------- REPAIR/ADDITION (Prev.:Sanitation Permit _-.-__-__-___--------- _ _____ _ _ _ Date -- -----------------Septic Tank (Specify Requirements)-=_-_:._----------------------- ,__'_ Disposal Field (Specify Requirements)-.4 __� - Q I ------------------ = -------------------- �� ---------------------_-- _ = ----- -------- --------- ------ ---_----------------------------------------------------- ----_____--------__---_- --____-_.______.-______.-________..__:-___.-_-__..-..---------------------------------____--___-__.________-_ $ (Draw existing and required add ition•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 Regula)ions 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 as to become subject to W man's CoCalifornia." ## { pensation-laws of Clif . � _ # Signed - BY-------- ----- ,l Title.- ---:- (If other than owner) 2 F FOR DEPARTtAENT USE ONLY APPLICATION ACCEPTED BY----- DIVISION OF LAND NUMBER------- ------- - L --- ------------------------ --•-=-._DATE.: -------C.-- - --------------- ADDITIONAL COMMENTS.------ �------ -- --- - � --- --•-.--- TE:--- ------ - -- -------------------------------------------- - - ------- ------------- -------------------- ----------- -------- -=-- _ . ----- --- - �_ k Final�lns ection b F - %-_ --- -- --�-------------------------------------- Date . , -[ . EH as sa SAN JOAQUIN LOCAL HEALTH DISTRICT --�. F&5 21677 REV. 7/76 3M