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till. . � -�'" FOR OFFICE USE: �" FOR OFFICE USE: 70- - - ! APPLICATION FOR SANITATION PERMIT ' ;7 - '-`--- ------------- ------- --------------- O {Complete in Triplicate} Permit No:��--7__,.-9_ . r --------------------------- Issued---,"-'/ -----i------ --- _______________________________________________________ This Permit Expires 1 Year From Date Issued 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: :. . JOB ADDRESS/LOCATI - ------ �R--- -- ---- - --=------=---------- -------------=-------- .CENSUS TRACT.- ----------------.------- m ``f .�.c.� "pft ---- ---- ----- ------ { Owner's Name ------. -- � ' = Phone �i Address------------------ `e ------ ------ --- - ��--- t-'uL ' --------------------_------City--- .. - -------------- ZiP l w ' Contractor's Name--- --- --- -- -- -----' --- C �.� --------- -------License --Phone rt? -- -------- --.------ Installation will serve: Residence = Apartment House.❑ Commercial [] Trailer Court ❑ ' ` Motel ❑ Other _ 01 t . . Number of living units:--- -.1.- _.-Number•of. bedrooms'-- _--_Garbage Grinder------------Lot Size_ U_ Water Supply: Public System and namek_+'-''- ---:__ rivate'❑ Character of soil to a depth of 3 feet:.. Sand ❑ Silt❑ Clay ❑ . Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ ' Adobe Fill Material............If yes, type-------------------------------- (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATIONC "(No'septic tank -or seepage .pit permitted if public sewer is available within 200_feet,) r cf PACKAGE TREATMENT '[ .) .' SEPTIC TANK �[Q Size.--._-S__-x_� --------------------- _________Liquid Depth.=�___-.-__-.-_-- -%,,•Capacity - -Ty _. ,r �Matcrial---4� GC�_�.�No. Compartments........... --- --------- ---� ),--(,;Distance'to nearest:-Well_._.`>__: --- --------------- -----Foundation.-------;(d__.______j._'P.rop. Line_____S7�1-------------- `, -' > S ir �1 Total Len LEACHING LINE w ^ Do $oxL�ne`'� e-Filter-Material .-- -____-- -Det � - ': - gth_____�-7________._--- ff Len th of ea h line l � f r yp p h-Filter Muteriai___' ______ • ;Distance to nearest: Well______________------------------------------Foundation. Z'6. Pr..i erty Lira _--".----------------------------- - SEEPAGE PIT Depth--2--,5.....1 iameter. ..f .. Number-------- ---------------------- - Rock`Fiiled-Yes No ❑ . Water TableDepth Rock : ize'_ --------------------- Distance.to nearest;Well--------_------ _---- _--------- __•Foundations___ ._' '-._.Pro Line----- k 3 R S . �f� r i REPAIR/ADDITION (Prev.-Sanitation Permit#-------------- -- --.----.4__Date _ _ } ! Septic Tank (Specify.Requirements)_ -------- - - -- ------------------ = :' z ) Disposal Field (Specify Requirements)-------------------- - --- - ------ ----_-----------------� - ' r ---- ---------------------------- F ------_--- -- ------ - ------- --- - --- i (Draw existing and required addition on reverse side E 4 I 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: r o "I certify that in "the performance'of-the work for which this'peirriiit is issued1,_Tshall 'not employ any person in such-manner as to become subject to Workman's Compensation,laws.of.California." + Signed_ tp -. --n- -aw e- r �-, B ------ - ------ y --------'=-_ --- - -- .,. _ OT.w.. n er rI t (If other tha - ti �. - - ... w . .. ! � � � OR DEPARTMENT USE'ONLY�J � � s ACCEPTED' BY-' _ ----------- APPLICATION ,,5 -' DATE.-/.. =�Y'=�r ------------------- DIVISION ----------------- DIVISION OF LAND NUMBER ---------------------------------------------------DATE------ ------------ --------------------------- ADDITIONAL COMMENTS--- -- - -- --- ----- -------- ----- --------------------------------------------- -------=-------------------------------------------------------------------- ----- --------------------------------------- - ------------------- ---•-------------------------------------------- ------------ ------- P y..- � �' (; �---- -------- - ----------- ----------------------------------- Final-Ins Inspection- _ ��- __.__ ---------------------------------------- -7 EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT 677 REV. 7/76 3m 1