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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ - (Complete in Triplicate) Permit No. 1`I _ 3 Date Issued5.-/--i_ - -------------- _ 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 � '-.- .--- ------ � -- --------------------- CENSUS TRACT � Owner's Name �z!. 'Z '-' -- -- ------ -------------- Phone_ Address -- - -Zip Contractor's Name G KN z --r ,,. License # z� -- - Phone— Installation will serve: Residence K�— Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other- - ---------- -- -- ----- Number of living units:.----/ -Number of bedrooms__—3 .Garbage Grinder____ ._Lot Size---- -t~-- Water Supply: Public System and name-------- --- - - ---------- --- - --- - --------- - --- ----- --- --- -------------------------- - --- Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loa mlClay 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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ I Size -- - ------- -... --------Liquid Depth ----------- ` Capacity -- - Type. . -- --- Material _No. Compartments Distance to nearest: Well . ------------------------Foundation------- Prop. Line ---------------- -------- LEACHING LINE . [ l No. of Lines _ ._______ _ Length of each line _.._..._ . __ _ Total Length _..__..._ . 'D' Box______ ___ Type Filter Material---------------.___ Depth Filter Material __________ Distances to nearest: Well . ----------- Foundation. ---Property Line_____________ ___.___..--- -_- SEEPAGE PIT [ ] Depth ----- _-- Diameter..__._.._.. Number______________ ___ _ -- Rock Filled Yes F-1No [] Water Table Depth ------ ----------------- - --- --- --- -------- .Rock Size------------ ------- - ---------------- Distance to nearest: Well ------- --------------- --------- -----Foundation________ ---------- _Prop. Line.... REPAIR/ADDITION (Prev. Sanitation Permit#--------_ ______________Date_ ___ . .----------------------- --- --- Septic -Septic Tank (Specify Requirements)____ __ _______ _ __ __ .-.----------- _ Disposal Field (Specify Requirements)_ _ _ c ___Ll, - --- `- --- �� G -� - ------ ---------------- - - -------- --------- -- ------------ ------------ ----------- --- ---- ------------ -- ------- --------------- -- - ---------------- (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: "1 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 rkman's ompensation laws of California." Signed-- - ---- ' Owner BY t -- -- Title. (If other than owner) ' _ �. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__..-. - - '-- -.'-- -- . -- ----------- - DATE -------- -- ----- ---- VIS ISION OF LAND NUMBER ___ - ------ --- -- DATE ADDITIONAL COMMENTS-- ------ - -- - -- -------------- --------- -- ----------- --- -- ------- ---- --------- - --- ------------------- --- -------------- -------------- -------------- ------------- --- --------- ---- -- ----- ---------- ----------.-- ---- --------- ---- --- Final Inspection by:------ -- ----------------- ------- --- Date _r / J - ----------- f -- -------- ---- eN is a4 SAN JOAQUIN LOCAL HEALTH DISTRICT ras 21677 REV. 7/76 3M