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fOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ _ _7j (Complete in Triplicate) Permit No------------- ---------------Tle- -- - ------------------ SCANJII' e Issued---------- ------- --------------------------------------------------- __.__ 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 applic tion is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOTION - ------- -------- --- ` -a PGLZ -:lf _. _- _ dUvi, #)f C N�ACT----------- - Owner's Name - -`---- -7r---- ------- - - -- ----- '---------------------- - . ----Phone< - p Address 1"- - �1 -(� - ----------------City- - -----------ZiPl�9/3/ Contractor's Name_____.______ ___ �_____ __ __ .6rt- -------------.----License #Z.� _'o� 3-----Phone __T�o�O_- 6� 7 Installation will serve: Resideno .Apartment House ❑ CommerciaX Trailer Court El Motel ❑ Other------------------------------------------------ Number of living units:-----_----------Number of bedrooms------------Garbage Grinder__----------Lot Size--------_____ --------- ---------------------_-____ 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 Fill Material__.______.-if yes, type________________________________ (Plot plan, showing size of lot, location of system in relation to weMs,.buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage ppit permitted if public-sewer is-available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Y 4 ize____ f (p - - Liquid Depth ��-- ----------- Capacity_/4(2_0P--- ---Type -)- ----- --------Material '-- --No. Compartments-------- ------ e� r Distance to nearest: Well------- ---------------------------1 � Foundation--Z ___.__Prop. Lirnez _------------------ el ---- r C r LEACHING LINE T Q No. of Lines-----------3___ Length of each line___--949_------_-----Total Length ____ -------;ZX I� 'D' Box----L"/_Type Filter Material-__ ___ ________.Depth Filter Material--------- -----------------------`___________________. Distance to nearest: Well----l_ _ _ —-------Foundation---- Property Line--- __'f"________________ 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)-------- ----------------------------------------------------------------------------------------------------------------------------------------- ------ 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: "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 toy Workman's` Compefisation laws of California." �C Signed------- ----------------- ------ Owner BY ------------------ Title --------------- -- ------------------------------- --------------- (I other than owner) f R D!f, RTME USE ONLY APPLICATION ACCEPTED BY------- - - ---------------------------------DATE.--- ---- �� -'r DIVISION OF LAND NUMBER_---- ------ ---- ----- -------------------------------- -------------------- - DATE ADDITIONALCOMMENTS-------------------- -------------_---------- ------------------------------------ --------------------------------------- ---------------------------------------------------------------------------------------------------------------- - -- - Final Inspection by-:- 4-------- ---- Date '� ------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M