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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I. _ C (Complete in Triplicate) Permit No.-. . . ..... A, Date Issued..3_J.O .7! ................----------.-.-. -----...--.- 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: r JOB ADDRESS/LOCATION. .-. ��. ft. . �-•--- �. •c"" .,��{��;:7n--- �.�------ ------ - - -----.CENSUS TRACT__.---- ---- Owner's Name..-. ..� , ' . Phone - Address------ ' . _... `� •1' _ CitY ...._ ziP Contractor's Name------- V r - - IPhone_ J - 1 _.._.. . . License #..�- -- ---� -- -- --•--...--- - - -- --.._. Installation will serve: Residenc Apartment Hou ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-,., ;t,,4.:A. .n... 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Li uid De th. PACKAGE TREATMENT ( ] SEPTIC TANK Size � " _- q p Capacity X_- ?1 (.TMaterial *'-r�' .-----No. Compartments-._...... _ .--- Distance to nearest: Well-------- _ - ...._..._._.Foundation--- '::, _*. Prop. Line_ _'`.. > . :�.... LEACHING LINE juJ" No. of Lines . _ ..............Length of each line..�`� `' ._'_Total Length Al D' Box_ . ..Type Filter Material Depth Filter Material_..--------!F--- Distance to nearest: Foundation -_-Property Line ... _ `"�............. , , v SEEPAGE P17 [' 1 Depth_ r _...Diameter_.. Number _ p Rock Filled Yes No ❑ __. . ...--•--.Rock Size . � .,. Water Table Depth-------- . <.: . `._.. .----- -_----------- Distance to nearest: ------- _-. _...... .__.Foundation..... f ....-.Prop. Line. r:_- _/t-----c•=_ REPAIR/ADDITION (Prev. Sanitation Permit#....-.-_------------------------- ---------------Date----._.---------- ------- --- - ---------) Septic Tank (Specify Requirements)-- --- -------------_ ---- -- ---- - -------- isposa Fie (Specify Requirements) _ - - --.__.. - ---- - - --------------------------------------- -- ----- ----- ------------ - -- - -- - ------- -- ------•-- -- - -- ------------ -------------- ........ ---I——------ •----- ------ --------- ----------- ....... -------- --- ------ ------------------------- -----...------------ ------------------------------------ ----------- --------- ------ _ ------------- (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, 1 shall not employ any person in such manner as gct" - - - � ,:... ------------- By �- -- � � -••- -- 'California.,, tobecomesubj I>sf W,orkman Com ensation laws of ' Owner Signed_--- It BY - - �//___- ---- ------ _ ------ (If other than owner) R D ARTMENT USE ONLY APPLICATION ACCEPTED BY -= ------ DATE 7 ------- . --------- DIVISION OF LAND NUMBER...._------ - ------- . DATE----------- ------- _._.._. ADDITIONAL COMMENTS-- ------- ....... ------- ----- ----------- - ------------------- --------------- ------------------------------ ---- - --------- - - _------- _-----•-•------------------------- ----------- --- ---- -- --- -- ... - ---------_......_----- -- -------- --------- ----------------------------------- -- Final Inspection b Date_. --- Final ---- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M