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FOR OFFICE USE: ✓ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT `® (Complete in Triplicate) Permit No..y?�•=1�� .. Date Issued-)d . ?.-I$ 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 o. 549 and existing Rues and Re ations: JOB ADDRESS/LOCATION .._...-.... - ------ �/ '�..� �.. CENSUS TRACT.-'-- Owner's Name.-- -- ,J..,------- - ------- ..................Phone_-- --------------- Address------ -.._ ..__ ._ = --------------- Cit 1 � _Zi Contractor's Name---- /C�t-r •---Z�"` _ --- ------_License ##fesG� F /// - -- Phone... ... / --------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--- ------ -----_- -- -------------------- Number of living units:----..../-..__Number of bedrooms-:Z _ Garbage Grinder - -Lot Size--. -41---/c/e_0?U..................... --.- 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 ill MateriaV`�'_.If yes, type---__------------- (Plot .- ------------(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 [ ] Size--------------_---------------............----------------Liquid Depth............_.-_.-._---- Capacity----------- -------TYPe--------------- ------Material-----------•-- .....No. Compartments-----•- -•------•---------------- Distance to nearest: Well.............-------- ----------- ------...Foundation--------.. _ .............Prop. Line-.........----.---.._-_._. LEACHING LINE [ ] No. of Lines .. -----------..............Length of each line------- _..........._-------Total Length ._ ------.------------.-_.._.----.-..- 'D' Box...._._ ..Type Filter Material-------- ----- .__Depth Filter Material_ ------.---------...---.-------------- .--------.---.-------- Distance to nearest: Well_..._............._.__-. Foundation.----..-._.--.._.-..._.__-Property Line..-..__....--- .----------.------.-. SEEPAGE PIT [ ] Depth.......... __.Diameter..------------- -----Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth------- -------_---------- ----------------------Rock Size-- _------ -_---------....- Distance to nearest: Well........__--- ------------_----- ......Foundation..... ------....... ......Prop. Line------------------ ..----.-. REPAIR/ADDITION (Prev. Sanitation Permit#...-__.-..._..................... ._---._.---...Date--...-----..-_..____._._..___---------.-.--] Septic Tank (Specify Requirements)-.__ Z. ---------- ---- ----- Disposal Field (Specify Requirem nts)------ - - ------ ------ --- - Vis..----------�1 r ---- --- ---X ..--•--._._.... . ---------- --- - (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 orkma ompensation laws of California." Signed.-------- 1. 61,4- - ---- -� ------------------------ Owner ..........-------------.Title.. ------------ (If - - (If other than owner) FOR DEPARTMENT USE ONLY ----------------- -------------DATE -�� -�� --- -------. APPLICATION ACCEPTED BY..:'� _. .- -------- ------ - DIVISIONOF LAND NUMBER._.... ---- - - -----------------------------------------_--- DATE------------.............................. ADDITIONAL COMMENTS --------- ------- ------ --- - ------------------------------ -- . . -------------- ----- -----. ................. ---------------------------- --------- ---------• --------------------•------•---- ----- ---- ------ ----- --- --- --- ------------------ •--------- ......... -- . . . ------------ ....... - - - - --------•- •---i------- ,---------------------------------------------� -- - Final Inspection by:---•- Date ^� EH 13 24 SANS J�IN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M