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FOR OFFICE USE: FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT ----------------- ------ -- ----- . ----� (Complete in Triplicate)ate) Permit No.,� - - ..—_ ..'�_.f... ----------- ---------- ------------------ ---- ......................................---------.......... This Permit Expires 1 Year From Date Issued Application is hereby made to theSanJoaquin Local Health District.for a permit,to constr etand_install the work herein described. This application is made in compliance-.4ith County. Ordinance No.`549 and existing Rules and Regulations: JOB ADDRESS/LOCATION__._ � _ ... .L____ ... ------------- ---- -- ---.CENSUS TRACT Owner's Name --------- y r- ----------- -- ---------. ............................Phone.----------- Address .. .. .. --:.. _:. ---------- City----------- ---------------- zip = Contractor's Nam ...... � -� .............._ #_-V l).� ...----License # 7/......Phone_ �- --------- Installation. will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ .. . otel ❑ Other........ --- - ----------- Number ----- - Number of living units:_ .._.`.•___.Number of bedrooms ...._Garbage Grinder------------- --( V.'"'-�................... ......... Water Supply: Public System and name--- ------- ---- - - ___ _ ----------------------- ------------- Private. Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ . Sandy Loam ❑ `Clay Loam [A Hardpan ❑ Adobe ❑ Fill Materiol�_._.If yes;,type........ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse,side.) C NEW INSTALLATION: (No septic tank,or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( J SEPTIC TANK [ ] Size_ .f _�C...{___�C__�.Q........... .....' Liquid Depth.::----.---.-.-.---- Capgcity.l- .pQ_..---Type. -- -- -- Mate,rial..__ _ No. Compartments....- ---- . '`f1 �---.. ..._ � � ..-----�------ Distance to neare,sf: VIIell-----__---�.0_ - - -----------------Foundation.... .. . _..'.........Prop. Line.._' LEACHING LINE [ ] No, of Lines...... Length of each Iine..._ ._��. .._......Total Length .../_797........------ ----------- _ . •D' Box.._. .:....Type Filter Material-__-. .. .. Depth Filter Material..../ ----- ------ ------------------- ----- Distance to nearest: Well.... .. p R...........Foundation__._.1-D------- .-. Property Line...._�............................ SEEPAGE PIT ( ] Depth_.. o�':..._Diameter._.-.. . ._ ....Number.._._'977......._._ '.___:: Rock Filled Yes ❑ No❑ Water Table Depth--------------------------- r Rock Size -— -- Distance to nearest: Well.------if' ---Q----------------------Foundation...f.. .....-.......Prop. Line.--.2'5--............ .-_.._ REPAIR/ADDITION (Prev. Sanitation Permit#-------------------- ..... ...............Date--------------.....°------------....... .._ --) Septic Tank (Specify Requirements)........... ... .... ... - Disposal Field [Specify Requirements]----.----------------. # ...............I.....---...------. 1 ............................. ............................. ----------------- -------- (Draw existing and required addition on 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed....... . - ... ...... - Owner By.......-• Title --- --------- --------------------- --- ----------- .._., --- t (If other than owner) FOR DEPARTMENT USE ONLY DATEVZ/. --. .. x APPLICATION ACCEPTED BY...................r� ........... ----------- ---------..._...- _ ......., DIVISION OF LAND NUMBER ....................... ------- - DATE.--- ... ADDITIONAL COMMENTS.. � � _ ... i _..... .. -...... ...... ---------------- ...6 �.k� ... - -------- - --- --- ............... •----- - ---- .- -- --- ----------------------- ------ -- ._... Final lnspectlon by:... - ----------Date._. -Z . ...... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 1W 77 REV, 7/76 W