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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- : Permit No.----------------------------------------------------------------------------------- �cu'�c 4 =f ' - ' (Complete in Triplicate) -- ------------------------------------------ ---------- - 1 Date Issued- ---$r-?g _ --------------------- --------- ___ 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 the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION-.-._-_---- _! _Er€<._, ,fes_____ ________CENSUS TRACT-------------------------------- Owner's ____-_ -__Owner's Name _/'rE y�2�z-_�_ Lc.L"z _ Phone - ---- ----- ---- /-�1 ---- --- Address-- --------"� ?` �'=' - _ _ �--------- ' _____-____License #_Contractor's Name ___ _ Zip �zz 7 _Phone Installation will serve: Residence[e Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------------------------------- ! i Number of living units:-----/---------Number of bedrooms_- _____Garbage Grinder------------Lot Size------- ____.-__------- 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 _ ---------If yes, type_--___________-____-____-____ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.)y^� NEW INSTALLATION: (No septic tank or seepage pit permitted//if11public sewer is available within 200 feet,) PACKAGE TREATMENT [ J SEPTIC TANK [7`} Size__ /__ ____!___�/ - __/--------Liquid Depth______ Capacity_,4A(,<7-------Type_ Mate-rial__.�__-�2 - ____-_No. Compartments-------------------------------- F4___IQ - SDistance to nearest: — Foundation -------Prop. Line- t _�h LEACHING LINE /No. of Lines_ ___1 _ Length of each lineCLterial ---Total Length _- ,�� ` t --------------- -- D' Box___/___Type Filter Material____S1� ___Depth Filter _._.--___-/J-.-- ---------------------------------------- Distance, ----________-___--_----------_ _Distance to nearest: Well------ e?_ _Foundation__ -___ __ ___ _-_ __� Property Line_ 1---------------- --------. f` _Number_______ _ Rock Filled Yes No SEEPAGE PIT [41 Depth ��Diameter_,__ >_ _____ ❑ Water Table Depth-------.----��"�-___� '__ _ .-_______Rock Size____ __ ' --- ----- - -------------- Distance to nearest: Well------ _ ._ __________Foundation___ _ Pr_op.-_)L ine REPAIR/ADDITION (Prev. Sanitation Permit#--_______-______ ___-.________._______._.Date_______________________-____ Septic Tank (Specify Requirements) Field (Specify Requirements)--------------------- ------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 to become subject to Workm 'cg f_ npensation laws of California." Signed--------------------------------- - F - ---------------------Owner L Title - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __ __ _ _ ______ DATE_ ---"--_-__ _ - ---------------------- - ---- - --- - -- -- ------- - DIVISION OF LAND NUMBER --------------------------- -------- --------- ---DATE---------------------------------- ADDITIONAL COMMENTS---------- ------------------------------ ------------------------------- ------------------------------------------------------------------------------- ------------------------------------- A `-J - - ------------ (77 -------------- ---- - r- ------- -- ---------- ---------- - ------------- Final Inspection by - .'�]`'� - Date - `'f �----------------- EH 13 24 1 SAN JOAQUIN LC7CAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M