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FFOR OFFICE USE: OR OFFICE USE: „�. APPLICATION FOR SANITATION PERMIT a------- -------------------------- �7 a .. (Complete in Triplicate) Permit No..------ -- ---- --------------------------------------------------- ri t. .. .. ate._ /5- / iso ► �""- ,. , Date Is - ----------.-------------------------------------- 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 rdinance N_q/54.9 and existing Rules and R lati s: JOB ADDRESS/LOCATION- +`- y- - -------- ---- - -CENSUS TRACT------ ---- Owners Name.----- Phone------------ ------ -- Address �/ � s --------------- City`s ?� Zip Contractor's Name -------------- - License #-� 1.x.3 -- Phone.A/'45 �----��,-/�--�{-l�"D � - -------- --- -f ..� 6 _ Installation will. serve: ResidenceW Apartment House ❑ Commercial ❑� Trailer Court❑ ; Motel 71 1 1 Number of living units:.___._ Number.o of. s_. ---_Garbage Grinder,�_..=_ Lot.•Size___ . T �. _, 5 - = Water Supply: Public System and name__ .... / Private i Character of soil to a depth of 3 feet: ° Sand ❑ Silt ❑ Clay ❑ Pe'at❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeW Fill Material-- ----If yes, type__.______._.__."_______ k f 1 (Plot plan, showing size of lot, location of system in relation to wells buildings, etc.;mu st be placed on reverse side.[ NEW INSTALLATION: -(No septic tank';or seepage -pit permitted if public sewer is available within 2d0 feet,) PACKAGE TREATMENT [ ] SEPTIC'TANK-[ Size- _ -- ------------- ---------------- __-----Liquid Depth ________________________ t Capacity-------------- yP _ -..Material -No. Compartments.-=------ - -----------=-- . Distance-to nearest: Well.--_.: -— _ ______Foundation ----------- - Prop. Line..-------------- F LEACHING LINE [ ] No. of Lines_-------___________-------------Length„of each line:...:.-_-._..-------____'.____:Total',Length -----------__------- ----------------- D' -________.__.._D' Box-:------..-Type Filter Material”MM--- -----------Depth Filter k M Depth...- - _ # My ateri-al--------- ----.----.----_------ --M----------- ------- '.Foundation-. Line----------- -______-o_-_Distanceto nearest: Well. _.__ _ _-- _m -----------.--= Nu _._-____ Rock Filled Yes ❑ NDia ..eterSEEPAGE PIT Water Table De th---- ------------ ----_---- ------_----.Rock - _-_- Size------- -------- -------- - ] "- Distance-to nearest: Weil---------------- �---.,,----------N`---'--Foundation---...--------------- _--Prop. Line------------------------� - REPAIR/ADDITION (Prev--Sanitation Permit#_'------------- ---- ------------- '_= -Date._----=--------------_---- -----1 4 Septic Tank (Specify Requirements)_-.-------- ------/ � ---------=------' -- ---�._. I ' 7 ------------------------- -------. ----- Disposal Field (Specify Requirements) ---------------------- 4 - v ------------------------------- - 6 i (Draw existing and required addition on reverse side) F i 1 hereby certify that'l have prepared this application and that the work will be done iii 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: -t ` "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.su Ie to Workma Compensation laws of.California.' Signed Owner. /y.. . . _. V�'r .-.-------. i By = - - _ -:Title = i '(If other than .owner) l s FOR DEPARTMENT USE ONLY 09 77 APPLICATION ACCEPTED. BY------ ------ =---- ----------- -----------DATE:- �'- ` --- --------------------------- •--- DIVISION OF LAND NUMBER------------------------ ' _---------.DATE.-.------------------ ADDITIONAL COMMENTS____________________ __ t ------ - ----------------------------- --------M----------------- ---- ----- - - -------- ----------- -; ---------------- ----- ---------- ..-. -:-- ------------------ -_ __ __-.__ A.__ -- 2______________ __ _______ _______ _ __ __ _ -_____.___._.__-_ �. ..a.��s� - Final Inspection by:------� _- __ = �"-: Date- , '- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 21677 REV. 7/76 3M