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FOR OFFICE USE: .r.� FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------- ------ (Complete in Triplicate) Permit No/../.... ...... Date Issueds " :.. ------------------------4;;',V1'0- 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 Count Ordinance No. 549 and existing Rules and Regulations: t JOB ADDRESS/LOCATION._1 �... . `� -�`� -------.....CENSUS TRACT..-- --------•- -- -- -------- . ------ - .... •-----. PhaneOwner's Name.......... 7- LA�-- --Address---- -------- Cit ------------Zi Contractor's Name.............---. .`_ ��-- -- -------.License #0.4.37_21-- --- -PhoneA,.Y.-. ol/6.---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.... ........- -... .. ............ Number of living units:.._: ..-----Number of bedrooms...-2'.. 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 wells, buildings, etc. must be placed on reverse side.) N11 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.------------- _----------------------- -- Liquid Depth.... .---._..._.._-14 Capacity...._.............. Type---------------- ----- Matevial--------- --...No. Compartments----- •--_-....._.� Distance to nearest: Well.........____----- -- ----------------.-Foundation------- - ----..... .. Prop. Line......--------.._........_ LEACHING LINE [ j 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 [ j' 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)__._ .. .... ..... ----- Disposal Field (Specify Requirement ) . ��,,.,��_j �►:..- 1---`== - -- --• s (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 or man ompe sation laws of California." Signed - --- - . Owner By----------------- -- --- --------- -- /�` .... ._ Title ' - ---- - -------------- ----- ------ (if other an OR DE A TMENT USE ONLY APPLICATION ACCEPTED BY-----..../u - DATE ... ....... --- DIVISION OF LAND NUMBER - - DATE----------------------- ---- ---- --------- ADDITIONAL COMMENTS_ ---- ...... - ----------- ... . .. ... .. ....... ------------•--------------- ----- -- ------------- ---------------- ......................................... ------•--....... ........ ................ --- ------ -------•--------------- .................... ..................-....... ------------- / . .-- ---------- rFinal Inspection by:. --- .... EH 13 24 - AJOAQUIN LOCAL HEALTH DISTRICT 9 F&S 21677 REV. 7/76 3M