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OFFICE USE: FOR UFFIGt tJSt: APPLICATION FOR SANITATION PERMIT `f 9� 5 Cr -------------------------- Permit No._.___.______ ._._.. - - - - - - ------------------- �__________________________ (Complete in Triplicate) "-" Date Issued..fo..'r�)-&::? _______________________----------.--------------..------- This Permit Expires 1 Year From Dat*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 a d existing Rules,and Regulations: JOB ADDRESS/LOCATION -._+_; '__- 1._ -..._ ______ 1_�'f_s' e�✓lai�,_-_____.CENSUS TRACT....... _-....__._ - z t � ------------ Owner's Name._--_ -. Phone-AO/ `T_'-� -- --. :._ -_ -------- Address---- 5r --•---Address - -Contractor's Name------- ------- .License #o522 PhoneA -.3- Installation � ' _... will serve: Residence Ig Apartment House® Commercial ® Trailer Court 14 Motel ® Other----------------- _ � - Number of living units:-./__.--_-__Number of bedrooms_ ._ Garbage Grinder--------.•.•Lot Size.....��-�: ----------------- Water Supply: Public System and name__ _._ J1? .�l !!T(�L_ _._. �- - ------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay® Peat® Sandy Loom Clay Loam ❑ Hardpan ® Adobe❑ Fill Material_. -_. ----If yes,type----- (Plot -_.(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 seepage pit permitted if public sewer is available within 200 feet,) ..l PACKAGE TREATMENT [ J SEPTIC TANK [ J Size__ ' '.: % .y `---_._._-_-..___-____--_ Liquid Depth---- ...... ._-_.-___..-_fl Capacity/_ �2V______Type: � - Material-------_---------_------ No. Compartments_...-..- ------ Distance to nearest: WeIL__'4 `'___ Foundation—/ _ _Prop. Line_ --- .,._- _..-. _ LEACHING LINE [A] No. of Lines --------;4-___.--_-__Length of each line--------7-9--------------Total Length. ------- 'D' Box__ _ .,_..,Type Filter Material��-Y-7'4, pth Filter Material------- _ Distance to nearest Well_''j_jt' 7__..----------Foundation__/h._._.___.__.---------Property Line_;.............. _.Diameter__-_____..__ _____Number___.__________________________ Rock Filled Yes❑ No SEEPAGE PIT [ ] Depth____. _- Water Table Depth.---- -------------------------------.-----.---.-----------Rock Size.------ ------------.--- _---- --..-_------:--- Distance to nearest: Well----------------------------_________•--.-Foundation_________________-.___.Prop. Line----......... ------`/j . , 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 wily 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, 1 shall not employ any person in such manner as to become subject> W rkman s- Compensation laws of California." , - =- - - Owner BY------- --------------- Title_--------- ------------ ----------- -------- .------ - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- --1 - ----------------------------------- ------------------------------ -----DATE ...__. "' „" r DIVISIONOF LAND NUMBER--------------- ----------------------------------------DATE------------------------------- ._._.-___.--_- ADDITIONAL COMMENTS__ -----------.___. _ --------------------- ------ ---. -------------------------------- ---------- -----------•----------- -- ---- ---------------------------------------------------------/ j �_ 7 -. Final Inspection b _______-------Date_..---- ------- _ _ --_--.----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ( /`/7)FSs 21677 REV.7/76 3M