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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT7 k, -y D (Complete in Triplicate) Permit No.__ ___ .......... This Permit Expires 1 Year From Date Issued Date Issued...1'-Z_-3"7_F 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--- � ------�-----------A_i+-,i3OF� � _A---------- ----------------CENSUS TRACT-------------- --------------- Owner's Name-. -------- -�y----------------------------------------------------------- --------------------------------------- _. Phone-_$150 -- ---�!5-�----- Address-- ---------ray./ s� _ Z J`, - - .L(o- / / JBIGT . /v --------------------------------CitY / ll.� � G'A Zip -- Contractor's Name------- /�1 2� Gt ----------------------- ------License #__o 'S ---Phone_-c5P_3_- --1w�G Installation will serve: Residence M Apartment House.❑, Commercial ❑ Trailer Court ❑ Motel ❑ Other---- ---------------------- ,` A C Number of living.i.rnits:,____________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 M Clay Loam E]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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth__________________.__ Capacity---- --------"----TYPe------------ ---------Material--------------------------No. Compartments --- ----0 Distance to nearestt Well---------- -----------------------------Foundation--------------------------Prop. Line---------------------------- LEACHING LINE [ ] No. of Lines------------------------------Length of each line-------------------------------Total Length---------------------------------------- 'D' ---___________________-_-_'D' Box------------Type Filter Material_--v_------—-----Depth Filter Material-------------------.------------.----.----_-------------------_. Distance to nearest: Well------------------------------Foundation________________________Property Line_______________---____-_____ SEEPAGE PIT [ ] Depth________________Diameter___________.___Number_____________________________ Rock Filled Yes ❑ No❑ WaterTable Depth - = > ------ ----------------------------------Rock Size------------------------------------------------ D�sta6ce to nearest: Well--------------------------------------------Foundation._._.---------------------Prop. Line -_-__-_. REPAIR/ADDITION (Prev-,Sanitation Permit#---------------------------------------------------Date---------------------_-------_-------____----_) Septic Tank (Specify Requirements)-------------------------- ------- - -------- - -- -------- ----- -------- --- ---- -------- ---------- --------- T F--T= Disposal Field (Specify-#equirements).-.---.- • -".G-* ---//IC C----------- - a------------Q2------------------------------------------------------ - ------------------------------------ -- (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 torkman's C pensation laws of California." Signed :. C. ------------------------------------Owner BY------ -------------------------------------------------------------------------------- ---------------Title-------------- ----------------------------- (If other than owner) on FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -- - - -- -------- -------------------------------------- -----------DATE_--- I ----------------------------------- ------------------- DIVISION - `'7 - - - DIVISION OF LAND NUMBER------------ - ---------- --- ---------------- ----- ----------DATE_. . ------ -------------------------------- ADDITIONAL -- ------ ----------- ADDITIONALCOMMENTS---------------------- ---------------•-- ----------. --------------------- - - ------------ ------------------ ------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- - ---------- Final Inspection by - -- - -- -- - --------Date--- !' -- 76--- -------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT so 21677 REV. 7/76 3M