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FOR OFFICE USE: liPIIATION FOR SANITATION PERMIT FOR OFFICE USE: --- (Complete in Triplicate) Permit No....................... 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. 549axis ing Rules and Regulations: JOB ADDRESS/LOCATION _-- .... . CENSUS TRACT................................ Owner's Name__ _ ----- .-------------- ... . .. .... Phone-----------_------_ Address-.-.---- City Zip Contractor's Name---- j-G---------------------------_------------- -- -------License ............. ... .Phone-----..:.---•-------............. Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------ ---- --- .._....--------•-•--•------ Number of living units:----......_Number of bedrooms...--. . Garbage Grinder---------...Lot Size....��'`�'`��'�'�� - - _ Water Supply: Public System and name_ ..-- ._ ._c ._/rr..5;%- n..___.__._..._. ________________ _--- --------.Privatevate [� Character of soil to a depth of 3 feet: Sand Ey gilt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AclobeZ 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.) -1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) {� PACKAGE TREATMENT [ ] SEPTIC TANK r��y� Size . ._%0.�'__S� ----------------------- Capacity- " 'L4] %I---------------------- -Liquid Depth. s Ca acit --- YP _..-- _ Compartments_ Distance to nearest: Well......... -------- .___...Foundation./40 . .... ........Prop. Line_.511......... LEACHING LINE [kj No. of Lines - ... aZ.................Length of each line...... .c - Total/Length ............. ------- 'D' Box.-Y-If�ype Filter Material.�.1-.,, _ .....Depth Filter Material_.....-t7... ......------------------------- -------_.._. Distance to nearest: Well.........."' .........__..Foundation._.... Property Line.... .__.. ...... SEEPAGE PIT J,r) Depth._. +rte.. Diameter_.. _.1*......Number._....°!X---------------------- Rock Filled YesZ No❑ Water Table Depth------- - .......Rock Size..-/','?.•. - ----------------•------- Distance to nearest: Well....-------------------------- *-----------Foundation--- _./P_.. .........Prop. Line._................. ..___ REPAIR/ADDITION (Prev. Sanitation Permit#................................... ...............Date..............----.--.__.....___. _....__._) Septic Tank (Specify Requirements)----- - - ----•-- -------------- ------- -------•----- •---------- Disposal Field (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 Compensation laws of California." Signed..... -- ....... ..... - --- -------------- _Owner BY----------- --- --------- --------- - ----------------•. -------------------- ---- Title..-.- -_1.-................ - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- - - -------- -DATE ... -_7?-.._ DIVISION OF LAND NUMBER__--------- ----- - _---- --------•--- DATE- ----- ADDITIONAL COMMENTS . -._... ;►-- '. _fi -------------- ------•------------------- ............. ............. /- Final Inspection by:-------------P2 ee...- --- -------------------------------- - --- -------------------- - •--_... Date....-.� ...°4_ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 77 REV. 7/76 3M