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FOR OFFICE USE: FOR OFFICE USE: ♦� APPLICATION FOR SANITATION PERMIT 7� f33 -------------LY. Permit (Complete in Triplicate) --••------------------------ ------- _1 Date Issued-L;,L.44:72.._ .....................----------------------------- ...... 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 a work herein described. . i I and Re at' s: This application is made in complja ce with County Ordin No. 549 and existing Rules Y,. . JOB ADDRESS/LO"ON_._. . . .. -N-------- E 5 S TRACT ---------- ------------- Owner's Name `-U.`�..... Phone- ..-------- ----- ------- ----- Cit -.. Address-- _. Phone. `�=--��- T ._.... Contractor's Name- .�:- p ._. ...... ..... License Installation will serve: ResidenceApartment House 0 Commercial ❑ Trailer Court ❑ Motel [] Other_.. ---------------------- Number of living units:....... ........Number of bedrooms._2J.Garbage Grinder/y! ...Lot 5ize..... .-. �- ' Water Supply: Public System and name-- ---------- - ---- -- �.. __..,_.�.,R-. ... . :_ .r .,- ...:.- ' --.- Private Character of soil to a depth of 3 feet: : Sand ❑ It❑ Clay ❑ Peat ❑ Sandy Loam j] Clay Loam ❑ Hardpan ❑ Adobe Fill'Material.. _,.. ..._If yes, type......... (Plot plan, showing size of lot, location of'sys em 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 ( ] SEPTIC TANK . [ ] Size............. ------------ ---------------- -----------"-.Liquid Depth..:. ........ Capacity-.--....1. ------..TYp Type---------------- Material. ---------------=---No. Compartments.: •- --------- . Distance to nearest: Well.:--------- ------------ -- --- - ....... . ........ -.Prop. Line-------- LEACHING LINE [ ] No. of Lines .'............................Length of each line-------------------------------Total Length -----------------.._.------------.----'T"f 'D' Box.... .--....Type Filter Material........... ....Depth Filter Material..---------_-----.------.------------------ ............ Distance to nearest: Well----------------------- ----Foundation-----------------------.----Property Line.....__..._--""----.----- ---- SEEPAGE PIT [ ] Depth_........ .....Diameter........---.........Number-.- ---------------------------- Rock Filled Yes ❑ Na Water Table Depth-------------------- -------- ----...............Rock Size----- - ..._ •---•------- Distance to nearest: Well--- ------------ ......... ......Foundation-.. -------- ----- ...Prop. Line ---- ..... ..... .. REPAIR/ADDITION (Prev. Sanitation Permit#......:...........:....... Date - ------- ------ ------) ' Septic Tank (Specify Requirements).--- - - --- ---- - Disposal Field (Specify Re uir ments).--..... - 9� / T-------Ig -,&�� (Draw existing and required addition on reverse side) 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 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 h to become subject to Workman's Compensation laws of California." Signed....------ . -- . . --- --Owner • ..... - ..-- Title. ----------------- ------------------------ By.'----- ---------------- ..-- y�� (if other than owner) FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY-;-----. DATE - -�— 1.... ...... DIVISION OF LAND NUMBER.. DATE -_.... ....................... .. ADDITIONAL COMMENTS....f/.- �`�Gvt. -------- ------------------ ------ ' t ... ......... .. ------------------------- -- ---•-•......... .... ... --- ... .... Qate ..._.... .... ..... Final Irispectlon b . ..... . .. r EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 V. 7/76 3M