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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----------I----------------------------- --------- d (Complete in Triplicate) Permit No._._ _7_T.___. ------------------------------------ Date 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: '172 , JOB ADDRESS/LOCATION = _: - --.CENSUS TRACT......=-------------:------ Owner's Name / _ ` �;` ------ ---------------- Phone � Address--------- � / -- -� - CitY --- ---------- Zip ---------- Contractor's Name-- --- ----- :� --------License #__ :Z Phone Installation will serve: Residence Apartment o se.❑ ;Commercial Trailer Court ❑ ' _ •Motel ❑ Other '' - - Number of living units------------g______Number,of:bedrooms_.___.-°,--_Garbage—Grinder------------Lot Size ____.__..______----_.__________________________________.___ Water Supply: Public System and name .. ------------t! /`L`------------- ----- - -- --- -- ---- •------------- Private ❑ Character of soil to a depth of 3 fest:i Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam E. Clay Loam ❑ -Hardpan ❑ I Adobe❑ + Fill Material._-_-`._..-.If yes, type------:``-------_"--______-__ (Plot plan, showing `,size of lot, location of system in relation to,wells, buildings, etc. ,must be planed on reverse side.) I NEW INSTALLATION:' "(No septic tank'°or see age ;pit ,permitted if public sewer is civarlable within 200 feet,) PACKAGE TREATMENT' [ ] SEPTIC,TANK"" Siie�7 ____/ _�-',�'- .__""---,--_Liquid Depth__--7:. I Capacity-_�CW-Ca _TYPe-' Material �'�`i'- No: Compartments-- '�- --� a li2?e -` 1 + __ _,Distance.to nearest.; Well-.'-. ------------------- Foundation ____.__F__Zrt__..-___.._Prop. Line_.____ �_____ _.____�___.,� LEACHING LINE;' E ; ......- = - , --.___--- -- :- 'D' Box-------- _Type Filter Material______________ __- -Depth Filter Material--- ------------------- - ------------------------------- :Distance --- --------------------Distanceto�ns�rest: Well ::-- :----_--------:::..Foundation---=------ - --Property Line - -- - ----- --- �---� SEEPAGE PIT :[ Depth:__�'r___Dlame.ter_.___._!T�_____Number_________.__.___1_____________ Rock Filled Yes [ No Water Table_ De th---=------------- ---q_ ----------- ----Rock Size'- -1 - p - - : Z Distance:to nearest: WelL: -�.. __ _______:__:_ t . . ___.__ -Foundation--- - --- -- .Prop. Line-------------------------- REPAIR/ADDITION(Prev:5ariifdeton Permit#_- ----------------- --------------.Date------------------------------------ <`- ) i Septic Tank (Specify!Require rents)--- '- ---- ----------------------------==-------------=----------------- ---::--=- -------=---:------:--------- ------------ ---------------- --------- i t : { Disposal Field (Specify Requirements)-- . .:_- ,.:::= --,--------------- ------:---------------------------------------------------- ---- ---------I----------------------------- • - _ '- - - ----------------- ----------------------------------------------------------- (Draw existing and required addition on reverse side) C 1 hereby certify that,I have prepared this application and that the-work will be done in accordance with San Joaquin Countyf% 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 shallnot employ tiny person in such manner:as a to become subject to.Workman's Compensation laws of...California." ------ Signed------------------- t------= "_. - Owner . _ ( . K By -= - = Title d 9�EC/ ---- ------ -------------=------------------- , (If other than.owner) FOR-DEPARTMENT USE ONLY;. i APPLICATION ACCEPTED BY ---_ --------------- ---DATE.------ -- r f/ 7r---� ----- DIVISION OF LAND NUMBER: -- --- --DATE --------------:--- ------------------------- ADDITIONAL ------ ------ ¢ ADDITIONALCOMMENTS----------------- -- ----------------------- = -------:------:---------------------------------- ------------------------- }-----------------------=--------------------------------------------------------------------------------- ----- -------------------------------------- --------------- -------------- ----- --------------- ------ ------------------ --------------- - ------ I_71 Fina "'. - a- ��{ Date ------- : - Inspection .Y - -- " p Y= ---------------- - EH 13 24 ��SAN JOAQUIN LOCAL H LTH DISTRICT F&S 21677 REV. 7/76 3M ,