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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y --------- 4.S (Complete in Triplicate) Permit No--- ...-_' --------------------------------------------------------- - Date Issued-./__3�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-------�-, _ - .1---- M...,�^^-��-- _ -------- 9----- fes' - -- --------------.CENSUS TRACT---------- --------------- Owner's Name..------ � 1c� ---------------- Phone---- F _ Address------ --------- *��' ---------------.------- ---------------------- ---------------City XV/11.-%CF�<=--A-----------zip ��--5_-�--��-------- --tN Contractor's Name----- License #__ � - Phone_ 1G.!r'l Installation will'-serve: ResidentApartment House E] Commercial E] Trailer Court ❑ l Lei ❑ Other-------- ------------------------------------ Number of living units------ ----------Number of bedrooms-,—I- -----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 Clay Loam ❑ 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 _ ------------------------^ Liquid De th.,__� _ J� [ ] SEPTIC TANK [ ] Size_-___.�_?s1l `�� ' Capacity_, Type_ G CJ .Material--------------------------No, Compartments------ __-- --------- ---------- Distance to nearest: Well...---�- �6 -------------------------Foundation.-/cam.- .Prop. Line.,.aC7 ; ._______-_._.__. LEACHING LINE' [ ] No. of Lines-----r X72/ ----- -Length of each line_� X_ ____..__.Total Length --- �____._•_ 47_ ce P, f i Jj 'D' BoxJ........Type Filter MateriaLAt�XQ�.Depth Filter Material----___/�------------------__ --------------_. Distanto neatest?'Vhetl� �72 �_____________Foundation._-!_0_--------------.--Property Line___----- _---_-_._.._____. SEEPAGE PIT [ ] Depth-.-- ---------Diameter----------.---------Number-------------------------------- Rock Filled Yes ❑ No ❑ WaterTable Depth---------------------------------------------------------Rock Size.---- ------------------------------------------ Distance to nearest: Well------------------------------------------Foundation-------------------------.Prop. Line._ ----------------- ------ REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date._-------_-. ) Septic Tank (Specify Requirements)-------------------------- ------ ------------------------------- -- ---------------- -------------------------------------------- Disposal Field (Specify Requirements)----------- --- ------ ------------------------------------------------------- -------------------------------------- -------------- ------------- -------------- _ ----------------------------------------- (Draw existing and required addition on reverse side) hereby certify that I have prepared this application.and-that th." ork-will be done in accordance with San 'Joaquin County Ordinances, State Laws, and Rules and Regulations+of the San_Jaaquin Local Health District, Home owner or licensed agents signature certifies the following: '9 certify that in S the performance of the work for which this permltris-issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws'of California`.=; i Signed - -- ----------------- --------------- -- --------Owner , ----- ---- -r BY-------- �c-- - --+--- c-- ---------------- T'+tle ------------------------------------------- ----- --- -- (If other than owner) ti r ; F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -- --------� --.--------`---{----`W`l--------------------------DATE --- f_2__-.Z,�-..r 777 DIVISION OF LAND NUMBER. '" -� ''+ . - DATE --: --- -- . n .- ------------ ------ ADDITADDITIONAL _... IONAL COMMENTS-------- -----------I --- ---------------------------------------- ---------------------------------------------------------------------------------- ---------------- - ------------------------------------------------------------------------------------ ---- -------- ----------------- ----------------------------------------------------------- ------------------------------------------- ----------------------------------- ---------------`'------ --------------------------------------------------------------------------- ---------- Final Inspection by:---------- --------- -- ----------------------------------- ---------------------------------------------Date.-- 77--------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M f