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� FOR OFFICE USE: T APPLICATIONFOR OFFICE USE: FOR SANITATION PERMIT (Complete in Triplicate) Permit No,17$.-.81 ... i ?, -- . This Permit Expires 1 Year From Date Issued Date Issued./4...:/Z.7�21e 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 incompliance.with Co my OrdinanceN , 549 and a fisting Rules and Regulations: JOB ADDRESS/LOATIO CENSUS TRACT:.................. Owner's me. OF, 1. iL� .......... ...... .. one 1 � 1�. i, Address- � �f .._. Cit Z3 �.. Y p-.._..------------- -------- Con#rector's Name__ Phone.__ Installation will serve; Residence ❑ Apartment House Commercial ❑ , Trailer Court ❑ I Motel ❑ Other.... Number of living units:................Number of bedrooms........ .Garbage Grinder............Lot Water Supply: Public System and name-- ------------------ Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam [❑ { Hardpan ❑ Adobe Fill Material.- _ ' __, ...Jf yes, type----- ------------------ " k (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTAL;ATION: (No 'septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.. Liquid Depth....:.:. ................ -- ! Capacity--- Type----- -----------------Mate•rial-•------- ......No. Compartments............... r ......--.. Distance.to nearest: Well-------- -----. ---._.Foundation..- . -- -_. ...Prop. Line--....................... LEACHING - - .. ... LINE [ ) No, of Lines ------------------------"-- Length of each line.....-----:-------- E - -- .... Total Length ...................................� f 'D' Box ...--....Type Filter Material:,:- . -.-.Depth Filter Material............"...... ..... Distance to nearest: Well----------------------------°Foundation." .......... Property Line-------........... ........... SEEPAGE PIT [ 1 Depth----------- - -Diameter------- ..--_Number..- - --- Rock Filled Yes ❑ No Water Table Depth.--. ------------ •-•-•--.Rock Size... ....................... i Distance to nearest:Well---------------- ........... ion............_......... - Prop. Line...........-_.- REPAIR/ADDITION (Prev. Sanitation Permit#----:--- ------------------ Date..---•-�-....:. t,- ------ ) . -- --------- Septic Tank (Specify Requirements)`- .-- ..-. - -" v' ► Dispose! Field {Specifyqements) �ur .-.__-- --- ... 1` '-'- '`�---- -- . ........... rt :ry ---------•--�-•-------•-----------------... ---------------- ------------------ (Draw existing and required addition on reverse side)" I hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents i signature certifies the following: l "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 becomerutT)ect to;Wan's om ensation laws of California." Signed--- �c] - - . -- • -- -------- --------- OwnerBY------------•--- ------ ..- Title-.----.. -- --------------------- ............... Of other than owner FOR EPAR ENT USE ONLY APPLICATION ACCEPTED BY- ......... .----..... .... ^.. ..._ ---------------------_-----.DATE __ ��.`, � _/..6...7...x'...-- DIVISION OF LAND NUMBER.-------- DATE: `. = - •------- - ----- - --._...------------......- Y ADDITIONAL COMMENTS..................... -------------- -...-_ �. .r ------- ------------- ------------------------ ------ -- Final-Inspett�on .b ~~ m Y -- - --------- ---------------- -"---------------------------------- -------Date.._...... ��' EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT C'B F&5 21677 REV. 7176 3M