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FORT OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No 1 J-- ---------- --------------------------- <--(..q'------------� (Complete in Triplicate) ----•------------ -------------- -- -- Date issued-R.' 7T.— -•-------- ......... 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.' This application.is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: II . �: ---------------•--. ---- -.CENSUS TRACT.............. ------- -------- -- JOB ADDRESS/LOCA N. .-1_l. - --. Owner's Name.- r �..��.. Phone...Y7 --_Z39 ..._.-- .. --- ----- _ City - -------- --- -- Address_ .... -r- ><. ........... ----- ----------------- License P = �o .- _....._:License - .-..Phone__?-._.-.. 7 Contractor's Name-------- _ ------- --- _ Installation will serve: Residence 79 Apartment House ❑ �K=Commercial`❑ -Trailer Court ❑ . -- ,__�' ' Motel ❑ Other------------ ----- ------------------------- 5-1y ---------- ----•-------- _ � � r. Number of living units:..--.---, ----Number of bedrooms-...— ....Garbage Grinder------------Lot Size_-_.-...... .... ......... -------�---.._-Private ❑ / Water Supply: Public System and name.. ...:................. -- ---"-" Character of soil-to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam X Clay Loam m Hardpan ❑ Adobe ❑ Fill Material _ ... ....if yes, type----------------- rf (Plot plan, showing-size.of lot, location of system in relation to wells, buildings, etc. must be pla�d �,rse side.) NEW INSTALLATION: (No -septic tank or seepage pit permitted if public sewer is available within 200 feet,[ PACKAGE TREATMENT [ ] SEPTIC TANK [ 1 "" n Size.--- --- ----- - Liquid Depth....."-----........... - --- • - No. Compartments------ Capacity --� --------------TYPE--- •---------- -..._.Material. -------- ------•-- -- - . _ . Distance to nearest: Well--------------------- -- --- ---- -- - •_-- Foundation-,-----.- . ----....- ...Prop. Line......... ........... TotalLength --- ----------••---------------------------------------- LEACHING LINE [ ] No. of Lines _.........................Length of each lin&.---------.-------- --- -- g 'D' Box_....... ....Type Filter Material.. Depth Filter Material ............... -- - ---------"- - Foundation::--r-:'..--- -- .. .Propertq� ine -- - {� � t Rock Filled Yes ❑ No ❑1 SEEPAGE PIT [ ] Depth................Diameter.---- Number...... -.x...==--- Water Table Depth-------•"--'-�.... ......... ... ............. • 1-------.Rock Size,_,__.. . Distance to nearest: Well..................... Foundation -...-. Prop. Line. REPAIR/ADDITION (Prev. Sanitation Per it#--------------- _---- ----- -.-_.---�..Date._.:_-^ .-----.------- -- � --------- Septic Tank (Specify Requirements).__ - �y f� �� _t--------------------- �� Disposal Field (Specify Requirements). - --- •- --------- _ ----." (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the workwill 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 M - to become subject to Workman's Compensation laws of California." Signed------------- -- ------ � ---- -- -...---- -- -----� ----. Owner N , :--------------- �. Title.--._... ( o her than owner) FO DEPA M NT E ONLY I - .--..-DATE .._....� ._ . . ... -APPLICATION ACCEPTED BY---------- - - --- - DIVISION OF LAND NUMBER -------------- ----------------- ------------ --- ------- -------- •........... ADDITIONAL COMMENTS-- .-----_--- - - ---- --------------------------; ---- ---- -----------fo!-- - �-- ... --- -------------------- .......... ...... y ----- -- ----- -- --------- --- •----.---.- ...... .. -- --• Final inspection b - ----- ----Date...._. . --- -- --...- y:...._..:.1 �+- F85 21677 REY, 7/76 3M EH 13 24 SAN JOAQUI OCAL HEALT IS CT