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t FOR OFFICE USE: FOR OFFICE WE: l APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No....... ....... ---------- ----•------ ----- ---.-- Date Issued.._'�-:../7_.7d ...... - "-•----• ------------- ---------- -- ----- This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin n Local Health District for a permit to construct and install the work herein described. r This application is made in compliance with County Ordinance Na. 549:njdxis, d Regulations: I JOB ADDRESS/LO TION_.'---C 713 .- _._CENSUS TRACT-------- -- .........>. kOwner's Nam --4 .. -_:..._.Phone- .. --------•-------- -- Address-- .. . ---- ------- - ----- - City-. ---��- - - ..... _. .--.. .Zip.�.�.,�y,J_.._..-- Contractor's Name..... �v4.......... .............License #2-1_�..�. .. --..Phone-- 2" --'1. Installation will serve:.. Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other`�j -�^ i '7'Y�•f� Number of living units:-...-./:..___.Number of bedrooms.- ..Garbage Grinder--.---------Lot Size__& . I Water Supply: Public System and name_ ..........:''_ .... --. _ Private - Character of soil.to a depth of 3 feet: + Sar-a ❑ Silt❑ . Clay ❑ Peat ❑ Sandy loam Clay Loam ❑ { Hardpan ❑-•1,Adobe [ }fFill Material . .. ' If yes, type (Plot plan, showing size of lot, location of systern,.in,relation to wells, buildings, etc. must be placed on reverse side.) NEIN INSTALLATION: (No 'se P't`i'c tank'"or seepage pit permitted if public sewer is av 'fable within 200 feet,) PACKAGE TREATMENT I' SEPTIC TANK 3 Siz ...... --. Liquid Depth.. -------------- I Capacity Type Material..----------- = No. ompartments - ------------ - Distance to nearest: Well...... " .. Foundation../-.O. _ ...:..Prop. Line�...d...................l LEACHING LINE FIF 1 _N'o. of Lines ---.- a-.•----------..Length of each line..-_- -4--____----.--- Total Length .. �. _�----- ----------------- ;' - •'D'-Box-__...✓.....Type Filter Material5.p.. oc_..Depth Filter Material......... .......---•-------...- Distance to nearest: Well----- ......_.Foundation---- Property Line SEEPAGE PIT [ ) . x Depth... ............Diameter--------- ---.Number- --.___ Rock Filled Yes ❑ No Water Table Depth Rock Size....---- Distance to nearest: Well................... --_----------Foundation---------------- ---------Prop. Line----------._....-.-.-.-_-... REPAIR/ADDITION (Prev. Sanitation Permif#.------.-_--------------------- -----------Date.............-...----------------------- ] Septic Tank (Specify Requirements).......................... -- -------------- --- -- -- - ------------- ------ Disposal, Field (Specify Requirements)- _ t • ....................... ...•____-_______••_•_____••__-_--_...................... ..................._ ..._..- IDraw existing and required addition on reverse side) I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin:1Cour0j 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'¢anner as to become sub`ect to Workman's Compensation laws of California." Signed -- --- ------ _ ------------------------ ----------- --Owner BY r/d- - - -.----- ��- ------�--- ---------- ------ -Title.. - �-- --- -- - _....---�--... (lf of er than owner] FOR DEPARTMENT Yg ON Y 44 APPLICATION ACCEPTED BY................. ADATE .....r�.-fa $ . DIVISION OF LAND NUMBER..... DATE - - --------- -------------------- •-----•---------------------------- ADDITIONAL COMMENTS____ :..... -------------------------- -- - —----------- ---..........- - ------------ .:..----- � Final lnspeciron by-------- - ------ Date _. .' .� -•-.- ; ----•- •------- -------------- ...------.. ...---.....----... I EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M