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"FOk OFFICE USE. T FOR OFFICE USE: - V APPLICATION FOR SANITATION PERMIT ----- •---------------- Permit No.--!7f-- [Complete in Triplicate] S/---- --------------------------------------------------- ✓I r =� Date Issued__ ____ _ ---------------------------------------------------..__.__ This Permit Expires 1 Year-From Date Issued i Application is hereby made to the San Joaquin Local Health District fog 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: ` AA JOB ADDRESS/LOCATION-J------ �A' :, ��` -- - CENSUS TRACT------ ------------------------- Owner's Name----------------- -------. L4j - ---- ---------f-'-=�...... - --------- Phone --- ------------------------------- Address ty ' .> r - --Ci _Zip �t Contractor's Name-------- d-:�1 - --------- ._.License # ----- ---XY3-----Phone__5Q_~ -7------ Installation will serve: Residence ❑ i Apartment House ❑ Comm rcial ❑ Trailer Court ❑ Motel ❑ Other _ ..__ .._____.____-- Number of living units:----------------Number of bedrooms-------- ---Garbage Grinder------------Ldt Size____.______ __________.__ ---------------.-.--____._.-.. Water Supply: Public System and name------------------ _ - -----------------`---------------------- ------Private. ❑ Character of soil to a depth of 3 feet: Sand Q Silt n` Clay ❑ Peat ❑ Sandy Loam ❑� Clay Loam' !Hardpan E] Adobe' Fill Material-----------If yes,-type---- ---------------------------- {Plot plan, showing size of lot, location of system 'iff relation-t-o wells;-buildings,-Vc. 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 -'e' -- - [ ] SEPTIC TANK ��]��.. --- Size-- --- ----- -------------------------------------------- Liquid, Depth. -----01C Capacity --- -------'" = '•Type-- _-----------------Material-------------------------.No. Compartments-------- ----------------- Distance to nearest-. Well-------------------------------------------Foundation--------------------------Prop. Line.----------------------40,�, LEACHING LINE [ ] No. of Lines-----------_____,length of each.fina. F� _ .� Total .Length 'D' Box----l-------Type Filter Material--------------------Depth Filter Material-------------------------.----------------------------.---- Distance to nearest: Well_._,'._ --_�_______ ____fouridafionk___.___.c__�=:*_�_.�_.._Property Line.______________._________-._ SEEPAGE PIT [ ] Depth------I---------Diameter--------------------NumbVr---Y--------s------------------ Rock Filled Yes ❑ No Water Table Depth----------- --- ------------------- -------------- 4__I.Rock Size------------------------------------------------ Distance ---------------------- - ----------------------Distance to nearest: Well------------------------ -------. Foundation--------------------------Prop.Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#___________ _____..___ SepticTank (Specify Requirements)-------------------------- ----- -----------s-- ------------------- ------ ---------------------------------------------------------------- ------------ a r .. Disposal Field (Specify Requirements)____,....-.a._,a. .60' Q____ - 5_.__._.- -.�._. '�- ---------------------------------- -------------------------------CAI 4�=`-t -------------------------------------- --------------- -------- ------ -------------------------------------------------------------------------I---------I-------- --------- ---------------------------------------------—------- -- ---- ----- (Draw - - --------------•---------(Draw existing and required addition on reverse side) ..------------------------------------------------------------(1 h 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 agent 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�:J to become subject to Workman's Compensation laws of California." Signed- - ----------------------- -------- Owner (� By-------- -------- --- -------- ----------- -Title-- ! other than owner] FOR DEPARTM T USE ONLY l APPLICATION ACCEPT D BY-.---- -- DATE.- DIVISION OF LAND NUMBER._. -- ________________-DATE._.________._._ ADDITIONA COMMENTS- ` Jam- - .1 -J-------------------------------------- ¢ F ----- -- ---------------------------------------------------------- - --------------- - ----- -- ._.� -� ---------- ------------------ ---- - -- ------------ -- -------- --------------------------------------- Final Inspection by:- ----- . ---- ---- --- -- Date �� r� EH 13 2A SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M ti �r-