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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No...........:........... ---.... ................. ......................... Date Issued.-/..�_/6-'.7 ...........1.........................:..........-... .. 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. i This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations; JOB ADDRESS/LOCATION - �. Q - .........--••---- ---....CENSUSTRACT--.-----• -------- -• ._......._ Owner's Name --. 6 " ��7 Z Ct r ..............*_.....:.. ----------------- ----- ----....Phone.. 9 00 Address � Q ��- -II Ja s City - . ---.-------__Zip Contractor's Name ,.. ...... ..... ......License #-_ �/-`3 j....Phone-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel r❑ Other ------------------ a , Number of living.units:-.-- ......Number of bedrooms....a�_r....Garbage Grinder............Lot'Size---... Water Supply: Public System and name------------------- --•-•-------•-------...----.------....---...........--_--- ..Private Q Character of soil to a depth of 3 feet: Sand ❑. . .Silt F] Clay ❑ PeatEl. Sandy.Loom,!W Clay Loam ❑ [ Hardpan ❑ Adobe ❑ Fill Material _ __; If yes, type................................ {Plot plan, shawipg 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,) ,/ PACKAGE TREATMENT [ ] SEPTIC TANK` �Q Size -.` .V? - ` X .--..._._.._--.Liquid Depth..--7...-._-. Capacity./20 -Typel ...✓ ...Material--- .r-...-:No. Compartments.---- .A-71..........-- f` 01 - .-- Distance to nearest: Well-:-- 8...................... ... ....Foundation..--�d. ----.. ......Prop. Line-- --------- -- LEACHING LINE �' ' No, of'Lines'" -._.Length of each lina.y�.- 4-..y�..---Total Length -. 0 -a--- -- _- 'D' Box *0" Type Filter Material ;5.e .Depth Filter Material.........le-------------------------- ! �- S� Distance to nearest: Well--- -..--.---- - Foundation..---/40-- .----..Property Line--.. - -.............. f ri Water Table Depth. 33 f _-.--- '---- .t�...if Rack Filled Ye-1:21' No ❑ a SEEPAGE PIT De th-.O? Diameter-..- Number_-_-- ___ p P ��.---- - .---.Rock Size-- �/� ---- Disfiance to nearest: Well.--- a'Q.�- - --- ----.-----.Foundation.-.4.0.�..--.....--.Prop, Line.-��7.................. i REPAIR/ADDITION {Prev. Sanitation Permit#-----_.--....-. = -.Date------- ..............................) Septic Tank (Specify Requirements)----------- - e -------------------------- ------------------------ - -- -- . .......... Disposal Field (Specify Requirements)....-..-.. -------- le -------------------------------------------------------- --- . -------- ---------------- -- ---- v (Draw existing and required addition on reverse side) I hereby certify that 1 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: 't. "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 becom ble t to Workma 's Compensation laws of California." Signed------ --- - --_Owner f � . --....----- .BY �� .. (if of r than owner) OR PEPARTMEtAYSE ONLY APPLICATION ACCEPTED BY..: .--.... '�" ... ° -------- ------_DATE -.. - 7. .............. DIVISION OF LAND NUMBER.----.--_---.. � ---------------- - -----------DATE....--..._ ADDITIONAL COMMENTS. ..... ........ ............................... ........... - -------------- ----- -------• -------- - ..............•--•----•--------------------- ----. Final Inspection by:-- //�- -- �: _ - ._.. •- ---- -------- •-Date. f ......--- - i EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M