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FOR OFFICE USE: FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT ------------------------------------------------------ (Complete in Triplicate) Permit No. Z rSS -------------- ------- --------------------------------- a Date Issued- --------------------------------- ---------------- ssued_----------------____-.____--___----_-___---- ----- 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/LOC ON !� "'- = '----�` ' �{ --------CENSUS TRACT ------ -------- Owner's Name - ---- --- ----- ne Pho ..z - City C -a� _ ` C ZiP ^`r� C Address--- ----- f t- ---- Contractor's Name--- �" 4 -- l� - Phone---------------------------------- Installation ------- -------- ----------- < -L License #_ - Installation will serve: Residence ZJ' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------------------- -------- -- - ----------- Number of living units:--------I------Number of bedrooms- ---Garbage Grinder------------Lot Size-______--_ F`_ --------- " '� WaterSupply: Public System and name------------------ --------------------------------------------------------------------------------------------------------------Private [�J` Character of soil to a depth of 3 feet:/ Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan E 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 see ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Sizd)l-' --— f____ ---------------------------------Liquid Depth_ ---_ -_-__s Capacity_1W f-^---__-Type-- U,'_, 'l-Material . ------------No. Compartments------------ ompartments � -. - 00 Distance to nearest: Well-_--_ —- _ _______ Foundation ------ Prop. Line__ J LEACHING LINE [l No. of Lines-------------- ----------- Length of each line--------- '-_ - -----Total Length __---1_ _ -_ _ - -- D' Box-----I-----Type Filter Material-------- ... ----.Depth Filter Material-----A----------------------------------------------------- Distance to nearest: Well------I _ t FoundationF---------Property Line-------- --__________-____.• SEEPAGE PIT [ )] Depth-__�J/Diameter-------------.'_'_--Number_____________ _______________ / Rock Filled Yes ❑-- No ❑ Water Table Depth-------------/ t------I--------------------------Rock Size--- `l- ---- ---------------- Distance to nearest: Well---------- ------------- - r -----------Foundation__�_C _ -`____ __ __ Prop. Line--------- �r__ ____ i�-- REPAIR/ADDITION (Prev. Sanitation Permit#__________________-_---------------------_-.Date----___-_________________---------------) p SepticTank (Specify Requirements)------------------------------------------------------------------------------------------------------------ -------------------------------------------- Disposal Field (Specify Requirements)____________________ ________ ----------- ------------- --------------------------------- ------------------- --- --------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 to become subject to Workman's Compensation laws of California." J� Signed--------------------------- - l�'- < - ---Owner By t/` i r ` ,` Title Yg ? --'--------------` L ------- -------- -------------- - G 1 (If other than owner) `` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ /_- ___________ DATE.__--! "'-- - -"-"-- ---- --- - �� ---- - DIVISIONOF LAND NUMBER--------------------------------------� -----------------------------------------------------------DATE------------------------------- ---------------- ADDITIONAL COMMENTS----------------------------------------- --------------------- ------------ ------------------------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------- - - --- ----------- - Date Final Inspection by:---- - - - � --- EH 13 24 SAN JOAQUIN L AL HEALTH DISTRICT F&5 21677 REV. 7/76 3M