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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------- // (Complete in Triplicate) Permit No........." _�� --------------- - ------[ i This Permit Expires 1 Year From Date Issued Date Issued__��<"�tF7_-72 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 -------- -a1------L-- ------ �'"------------------------------------------------------------------------ ---Phone-------------------------------------- Address / ' �� ------- - - Zip� --- ----- - ---- ---------- - - - CitY ----- Contractor's Name----- - - ---- ------ - - - -- -- ---- KJ�----------------License #-_ ri .2Z ---Phone------------- ------ Installation will serve: Residence[C Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------------------------------- Number of living units: 1 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 P�-- -- 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 see --------------------------- ge pit permitted if public sewer is available within 200 feet,) l r � PACKAGE TREATMENT [ ] SEPTIC TANK [ Size__ .__!t~�O.___ _S__ _______________________Liquid Depth._-_��___.____._--_0 Capacity/6�-!;�---------TypeL.,, __ Material__.. --.----No. Compartments-___.-- ---------------.--_J Distance to nearest: Well_! /--------------Foundation---__-�_�__r-----_----Prop. Line___--74------------------ 1 LEACHING LINE [r'J No. of Lines---------3 _ __---.-___-.Length of each line.----- --=-'� otal Length -----1-S-2© --------------------- 'D' Box m Box____4____Type Filter Material-__-__JC..Z_-_-_Depth Filter Material_______ _N._ Distance to nearest: Well------- //"/-----Foundation-_- ____-__/6��-__Property Line_____�ro-- [ Depth_,r,�.______-Efer., ___.C_ ___Number-___.--------_�_______---_ Rock Filled Yes (/No ❑'f Water Table Depth----------------�_---------------------------Rock Size.-Ili - ----------------------- -____-_____-_Foundation Pro Line.._________ _ Distance to nearest: Well_____� � _ __�._. p. �C _______.___. REPAIR/ADDITION (Prev. Sanitation Permit#______.-_--_-________________________-._____-Date________________---------------------------- -) SepticTank (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: - "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 Workman's pensation laws of California." Signed------------------------ - ----- - - - - ---- ---------------------Owner n^'n �, [�` BY ✓YLGG- ----- ----- --------- ------ Title._. B'at-- ^4Rt ---------------------------------------------- (If oth than owner) t! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- a� / aa�i�'t- -/-------------------------------------DATE.------- d DIVISIONOF LAND NUMBER----------- ---------------------------------- ---------------------------------------------.-DATE----------------------------------------------- ADDITIONALCOMMENTS------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------�----------------------------------- -------------------------------------------------------- ----------- ---------------------- ---------- ----------- ------------------------------------- --------------- -- - -------------------------- - - - - ---- -- ---- �--Final Inspection bY:-------------- --- - Date EH 13 24 �F&S 1677 REV. 7/76 3M� SAN JOAQUIN LO L HEALTH DISTRICT ,