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FOR OFFICE USE: FOR OFFICE USE: �'+. APPLICATION FOR SANITATION PERMIT ----------------------------------- (Complete in Triplicate) Permit No._��"__:_��_� Date Issued_/-a"2/- ------------- 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-- f'-T/7 - - E :�'' - le I ----------------------------CENSUS TRACT--------- ------ ------------ .c L Owner's Name----- C J'a �t�t.-r � r�r Z � � �� ---Phone----------------------- --------- c- J-7— C7Address--- --- --- ------ Zip-- ---- ----- _ 1 ---- ------- CitY -` < �Contractor's Namen - License # Phone ---------------------------------- Installation --- --- ----- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------- --------------- Number of living units:-----___J-----Number of bedrooms----- ___Garbage Grinder------------Lot Size_-_____fL_-__ - e?j--_ Water Supply: Public System and name---------------- --------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet/ ' Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam E-] ClayLoam E]Hardpan U 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,) - �� PACKAGE TREATMENT [ ] SEPTIC TANK [/J Size��____�L'_j________________--------------------_Liquid Depth.--- ----__________- Capacity__f;7c 4'---------Type_ _Le__',_�---Material_,i!ft-v--1---------No. Compartments______________ v Distance to nearest: Well ________-1`_e— ____________________Fou`�ndation________l ____Prop. Line___--Lf�_______X, LEACHING LINE [y] No.,of Lines__..____________________Length of each line_____7_-1 ________Total Length _ e ;_________________ 'D' Box____- Type Filter Material_______ /------ De th Filter Material-------C Distance to nearest: Well_______!/e—___.__Foundation______lC ____Property Line------ - _-____________- SEEPAGE PIT (✓ Depth_-_ =r_(_Diameter______�_3 ---Number-------�------------------ `e', -Rock Filled Yes [7� No ❑� Water Table Depth-------------- _Ce-_�^ �- `F � ---- -- -- ---------------Rock Size - -�;f.� .�'--�------------------------- Distance to nearest: Well------1k, I -_-_-__-__________Foundation______` _.Prop. Line_______5 _ REPAIR/ADDITION (Prev. Sanitation Permit#____________________________-____________-__.Date___________________-________________._) SepticTank (Specify Requirements)-------------------------- ----------------------------------------------------------------------------------------------------------------------------. o DisposalField (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 Workman's Compensation laws of California." r Signed---------------------------------------------------- -----` � - Owner .- - -�. --------BY Title �` (If other than owner) , FOR DEPARTMENT YSE ONLY �` APPLICATION ACCEPTED BY------ -----_ DATE (�- - - DIVISION OF LAND NUMBER ---------- -- -- ---------------------------------------------------------------DATE-------------------------------- ADDITIONAL COMMENTS -- - ---------------------------------------------------------------------------------------------------------------------- --------------------------------- ------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------- - -- --- - ---------------------- ------------------------------------------- - --- ---- -- -- - --- --- ;r-` -- c am-- S - �` Final Inspection by: - - ---------------Date EH 13 24 " SAN JOAQUIN LO. AL HEALTH DISTRICT F&�SJ21677 REV.7/76 3M `�(!/