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FOR OFFICE USE APPLICATION FOR SANIT�ATION PERMIT FOR OFFICE USE:7G (Complete in Triplicate) Permit Noh_._ / .... This Permit Expires 1 Year From Date Issued Date Issued- - 7-J 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.� 9 and existing Rules and Regulations; 4 JOB ADDRESS/LOCATION.-,. --- t .... .U ------------ - - --------- ....... �--------- CENSUS TRACT..---- Owner's, - ..--...Phone.--------- --------- ......... Address---�------ - ....... . y.... - ----- -_Zi -- � Contractor's Name..... _..-.- ,• t --------License #--- -_ .Phone... 2 Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ 4 Motel ❑ Other.. ..... Number of living units:------.J_------Number o{ bedrooms._.... Garbage Grinder___._..-.-,.Lot Size....-�.,x C� ....... •----- - Water Supply: Public System and name.... . -- [ �� ------- --- ----- - �------------- ............ . �--�----•- ---...---Private E] Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Clay ❑ Peat [] Sandy Loam ❑ Clay Loam ❑ I Hardpan ❑ Adobe ❑ Fill Material._ . -...If yes, type........................ ...... [Plot plan, showing 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 [ j SEPTIC TANK `� L 1.. --[ ] Size.. .�'�!`�/L---€�---�L- -1�•---- ------ ---Liquid Depth. ------------.....0C Capacity_.- O� Type.... ..........Material---If(,J. ------No, Compartments-------9-s�-.- A Distance to nearest: Well..._ - .......... Foundation..../_D -_-..._ ..Prop. Line...../..d------- �1 r LEACHING LINE [ ] No. of Lines ...�- -- ..Length of each line--- -- - !`1- -------- -- Total Length .1--��-.... ................. D' Box_.../....Type Filter Material..- '. . Depth Filter Material__ --../.� -. Distance to nearest: Well- Foundation....__.............. . Property Line..-. . .. - P Y �-------- ---- - -- r SEEPAGE PIT p 1I)� �� Number.. - -------------------- p Rock Filled Yes No ❑ ] De th. D.iameter..._-- 1 _,-- . Water Table Depth. ------------- --- ---•----:--.Rock Size. : ,_- Distance to nearest: Well- -- - -- ----- ----- -- ------- -�.:'Foundation: .--- --------- Prop. Line ......................... REPAIR/ADDITION (Prev. Sanitation Permit#....-...-- /_f - ----- - ------_Date._..- ) Septic Tank (Specify Requiremenfs)._.._-__-_------ isposal Field (Specify Requirements)..............:........ ' ------ ---- ---- ----- ..-----.. .................. ------ ---- - {Draw existing and required addition on reverse si--de) I hereby certify that I have prepared this application and that the,work will be' done in accordance with San Joaquin County Ordinances, State Law`s,;'and Rules rand Regulations of ,the Son 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 an person in to become subject to Workman's Compensation laws of California." ` P y y p such c manner as Signed- - Owner By---- ----- - •----- ----------- ........Title---_....---.------- ....-----....... - ........_...._.. at er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------- 4 .--.-- ----------- ---- --------- -------------__------ -------------- .-...DATE . .--z- ..7�...... ..... ........ DIVISION OF LAND NUMBER. ---..DATE--- F....- ADDITIONAL�MENTS-s .��_ �, .--- . ------- tea, c--- -- - il -: - 3.1e ` .. ` - �, .�. '.' 4v------------------ ---- ------ Ar rJ .. >.. ------ .---------- �------ Final Inspection b - /` Y� --._....- --�'-� - - ------- - - - - - - - - - Date EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M v