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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- ---- �� (Complete in Triplicate) Permit No___ ___ ____________ ---------------------------------------------------- - � - 7I Date Issued__ " __________ __________________________________________________________ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District fora 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 � � ,. ----------- .: -` -' .CENSUS TRACT.- .............. ------------ Owner's Name-.---- � Phone. r _ Address. S" �`�'+ " - ---------- F = City. = dip Contractor's Name.--------- ---- -- - - ----License # 2 2 _Phone installation will:serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ i ...._... ._...,�. Motel ❑ Other_.. Number of living units: /------Number,of bedrooms -_-.Garbage Grinder Lot.Size__l4r_ __ --z� _�_n_ 1 --------------- Water Supply: Public System and'name....`,: -- --. .._ ::---- ------------------ ---`_ ---- -------- ---------------- � ._. ------.Private [� Character of soil to a depth of 3 feet: Sand Q Silt❑ Clay❑ Peat ❑ Sandy Loam ❑ 'Clay Loam ❑ E _ J aa: r s Hardpan Adobe ❑ Fill Material._:__-._..-.If yes, type------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,eAc. must be placed on reverse side.) F NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within200 feet,) PACKAGE TREATMENT [ j va SEPTIC TANK "` "t Size_?� __ :�____.!` _-- Liquid Depth---- iILaP.. Y- . Mrial= = __.: _No. Compartments _ p ____________________ ____ Distance tonearest:-Well ------------------- Foundation_._ � ------Prop. Line.".___:W___ ----------- to LEACHING LINE [ .] No, of Lines-:_________ _ _-__.Len th of each line.__. ,-._. �_ Total Len th. c = �- g = ; 'Length.-,., ----- D' Box ------/_----Type Filter Material-_------;' - --.Depth Filte�fMaterial-- ----- - -----.---------------------------------------'-- -Foun .,. , f Distance to nearest: Well. -------- dation._____ % ___.Property Line_______5 --.__.__.__i___.r __ N --------------v ) -- Rock Filled .Yes Z No ❑ .'. SEEPAGE PIT Water Table Depthmeter-,.-__l�-�-� -, � ; �clot } � � r . — 5ize __ l r �� ( Distance'to nearest: V11e11._ -:-- _1 1-2-------------------Found ation' _ -____.Prop. Line----------- _.____.. g k l � - 4` --- �, ---------- I if REPAIR/ADDITION (Prev.-Sanitation Permit#-- - :---- ----:Date_.-_---- :----- -----) Septic Tank (Specify Requirements) - - --- j''' . -----'----------------- DisposalField (Specify Requirements)-------------- ------- --------------------------------------------------------- -------------------------------------------------------------------i --- ---- ------ ------------------------------------ _ (Draw existing and requ'ir`ed addition on reverse' side). ' • t I hereby certify that 1 have prepared this application and that the work will be'do`ne 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 ceitifies'the following: i "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 i. to become subject to Workman's Compensation laws of California.'; t � Signed-----------------------------------------=- - Owner ' '~ SN -i.` gYr------- ----------------------------------------------- ---------=---- ----------- (if - Title' s (If other than'.owner) . DEPARTMENT USE ONLY'- + APPLICATION ACCEPTED BY----- DATE-___5 -- - - ---- ----:------ DIVISION OF LAND NUMBER---------------------=-------- -------------------=------'------------ DATE -- ----- ADDITIONAL COMMENTS---------------------------------------------------------------- -------------------------------------- --- -- --------------- ---------- ---------=---------------- ----- --- ---- -_---- --- --- ---=---------------- --------------------- -------------------------------------- ------ -- g-- r - t---- --- ------ ----- ------- -------- - Final Inspection b � � - ------------ 24 --- --- --- PY�=----------�---- �'. _ _." ..----- ------------Date-----------•---- --�- -- --- j 2A '''4� SAN JOAQUIN LOC L HEALTH DISTRICT F&s 2'�. 7/76 3M