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FOR OFFICE USE: �i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7_ � � -------------------------------- -------- ----------- Permit No... ---------- - (Complete in Triplicate) - ------------------------------------- ------------------ •�• Date Issued._ .-...._. ------------------------------------------__-----_--- This Permit Expires 1 Year FFom 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 County Ordinance No. 549 and existing Rules and Regulations: n JOB ADDRESS/LOCATION----_ _ ------ -----CENSUS TRACT_---------- ----------------- Owner's Name. -- ------- - i-�• !? =------------.-,..--------------------------------- Phone Address-------- 3 C� City z1P � Y I 'J" s Name r ---------- -- License #- 1 f Phone- Contractor'" y�s� Installation will serve: Residence ❑ Apartment House❑ Commercial ❑ Trailer Court ❑ I units ) A _ -P• Motel-❑ Other--- ----------------- - Garb /� Rge Grinder ..:.........Number of.liv'ng units: d - -°---Number of-bedrooms... f Water Supply: Public System and name-__ ------- _ .. .: - - - ~'�_- - -------- -Private E i Character of soil to a depth of 3 feet: Sand E--Silt ❑ Clay ❑ , Peat❑ Sandy Loam ❑ Clay-Loam f�( Hardpan ❑ ' ,Adobe ❑ Fill Mater;aL_.___'._--..If yes, type_.__-__------------------------ E- S (Plot plan, showing size of lot location of system in relation to'wells, buildings, etcmj must-be placed on reverse side.) NEW INSTALLATION:. ;(No se tic tank or seepage pit permitted if public sewer is available witl; 200 feet,) P a ------- PACKAGE TREATMENT= { t] SEPTIC TANK ['] ' Size-----_ / _� -- -- Liquid --- Cdpaaityl- . __Type- ---Material_-- -- -- _ No. Compartments._-•---� i Distance-to nearest:.Well---- - ---- ---- ---------- °Foundation---_:_--.-- -------Prop. Line--------------:-.---_- ---. a LEACHING LINE (:] No. of Lines:...__,.•. Length a' each line:___ s f 4 ,_ } A2----- ---To �1 - tel Length.: __ 1 'D' Box-:-I Filter Material:---_f_f -- Depth Filter Material._Y /_9--� -.-...__---- --------------------------------- 3 ; Distance to nearest: Well---_---!------- ------------Foundation------------------------------Property Line----------------------------------- SEEPAGE PIT [ ] Depth...'rp��._...Diameter- - °� _;N�n?ber�----- - Roc Filled .Yes [[ No El 1 Water Table Depth----------------I---- -= .� --=-- Rock Size, ---�. r Distarice'to nearest: Well_ ___ - ----- :Foundation---------_'____._._ --___.Prop. Line------------------------ - REPAIR/ADDITION (Prev, Sanitation Permit#-------------------------_----------------"---- Date---------------------------------------- ----- Septic Tank (Specify Requirements)--- ------------------ ---=----------------= ------------------------------ == ----- -------------`- I Disposal Field (Specify Requirements): - ------ - ---------- -.--- -.--.-------- ------ -- --- _ ----------------------------- ----------------------------------------- ------ --------- ----- (Draw existing and requi.red 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 petlormpnce of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to. Workman's Compensation' laws of .California." • F;3 Signj;i ed -------------- t .�, ------= -Own e -. itle 4 pp TwB -If'other than'_, , ner ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-iI-- :.: --- --------------------------------------DATE./------1 -7=� ! DIVISION OF LAND NUMBER'`- _ -------------=-----------------------------------------------------==---DATE--------------------:-.----------------- . ADDITIONAL COMMENTS__: ------------- ---------- ---------------- ------------------------------------- ------- - -------------------- -------= -------------------- ----------------- ---------------------------------=----------------------------------- ------ ----- ------- -------- t aG---------------------------------------- --------------------------------------------------------- - Da#e./ --------.------------- Final Inspection by: - ' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fes seen Rev. /76 aM u .� -