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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No ---------------•--------------- j - )Complete in Triplicate) --------- --------------------------------------------- . Date Issued--�d�7"_�� ----------------_-------_______.._---------_____-___.__ 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: JOB ADDRESS/LOCATION - ------- -.-.Phone b} is tc9 --D .. CENSUS TRACT Owner's Name ;L-ti--- --------- ------------ �T' -------- -- --- Phone. Address - =: ------=-_--- - ---- City _ ------ ---------- - C _. �- - Zip Contractor's Name. ¢ - ---------Licen e -�3� B--Z ._ one. ,------ - F _� Ph Installation will serve: Residence ( Apartment House.0 Commercial 0 `Trailer Court+❑ 4� i t .Motel ❑ Other--- ----------- ------- --------`- Number.of living units ,:_ fi Number of bedrooms `J Garbage Grinder.- •r___ Lot Size ___. ------ - --- j' Water Supply: Public System and name,__. ---___.�' ------------------------_ ' - TM_ _ ---Private _ _ - - t Character of soil to a depth of 3 feet: Sand ❑ !It EJ 'Clay ❑�+ Peat ❑ Sandy Loam EJClay Loam ❑ Hardpan_❑ Adobe Fill Material__-- -------If yes, type___._._-.--_-----_ - ' (Plot pian, 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 seepade pit permitted-if-public sewer i available within 200 feet,) I SEPTIC TANK [ ] Size--- ---- Liquid Depth.1------------------------- PACKAGE TREATMENT' [ ] PYType-.-,,it, a al�_- = No. Compartments ----- ---------------------- -'_---� Distance to nearest: Well.-------.---------Y---j..:__. _ $ Ca tacit y1 = Mater)_ ._,:Found,__. �__ ..._ Prop. Line =- --=-------------� ` LEACHINGation..__. _ LINE [ ] No.sof Lines ----- ---- -.--- ------.Length of each Tina=---- ------------Total Length-----------------------------------------f ' 'D' Box-- ------'--Type Filter Material-------- ------Depth Filter Material--------------------------------------------------------------- --------to nearest: Well_: '___. Foundation.__. -_____.Property Line-__._ _ __________ '- - .z o [ SEEPAGE PIT [ ] Depth-- ----- ----Diameter--------------------Number- . -=-:--- ,'-,` -- - t� ,�,Rock Filled Yes ❑ No ❑� Water T661e.De th---- -- ---- --- ----- ---- ----.Rock Size---------------------------`------------------ 0 .---- ----- r Distance to ne6rest: Well---------------------'------------------`--:Foundation',_.__=_______------ _.Pro 'Line REPAIR/ADDITION-(Prev. Sanitation Permit#_.:__.----- - -----------------------------------=---=--�--a--_---Date--a---�—�--'-----_- --`- -- - ----- -----=------=---------- - � --- ------ ---------------------------------- ----- ---- 1------------- ---- -Septic Tank (Specify Requirements).----;_ : ' ' o -Dip sal Field (Specify Requirements)--- "�`-� --4!,� `y'-'- ------- �1 --- ........ ---- . -------------= _ ray �. ti: - = '- zs ---------- - P1i Draw i�hc stir and required addition on reverse side) f g q 1 hereby certify that 1 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-------------------- -- -- ------- --------------` -- - - ------ --- By-1 - Owner BY-i-------------- ------------------------------------- ;�G��--'-Title-- --- - _ --------:------ :- -----------=- ------------- -- ( (If'6+e-r than owner) t FOR DEPARTMENT USE ONLY 4 APPLICATION ACCEPTED BY------- ------------------------------ DIVISION = _ DATE) Y�7 - ` ---- DIVISION OF LAND NUMBER.---.------------- -- ---- = --- --. .------------------- ------------------------------ DATE.--- -- - ADDITIONAL COMMENTS ---=--- - -----------------------------------=-------------------------- -- ------------------------ - -- -- - F = --------------------- ----------------- ------------------- --- -- ---------=------------------- ------------------------_-----------------------=---------------- ------------------------ -------------- --------------- ----- ---- ----------------------------------------- ------------------------ --- _ _ f -------------------- --------------------------------- r Final Ins ection b "?•' _,--. +--------------=--"-_----------------'------------------ hate.. _' - ---- P Y:---- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M !i