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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No----------------------- ------------'------------------------------- �t 7 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT ON ! l �o \i �j� ------------------------CENSUS TRACT.---------- ------ --- --- Owner's - Phone. Address wner's �ry -- Y p � ---- ------- --- -- --- --- ---- ----- ---------- -----'_.City ---�"-�-.-_ ----- "-�-------...-------------- -ZAP---------------- ` a Contractor's Name------_ • License #_- 'Z _� '--.Phone...................... +- - - ----- ---=-------------------------- ------------ Installation will serve: Residenc eV Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------ -------- ---- --- --- ------------ Number,of living units:.-----._------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 ❑ 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 see age pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT .� � � [ ] SEPTICTANK [ �,' Sizer.. .1 .---- ----� Liquid Depth..- V.-. - Capacity.16Z---------TYpe-J a v-Material-.C.9/--£3------.._No. Compartments-7�------ - --------------- Distance to nearest: Well.... 101---------------------Foundation--------- 1__-_---_Prop. Line______________________... LEACHING LINE [01 No. of Lines--------rz-----------------Length of each line------..r�X,1�-----.-.Total Length.--... ---_-__________ 'D' Box....I------Type Filter Material----- - ------Depth Filter Material-------_f- . --------------------------------------------_ _ Distance to nearest: Well____'C-�-Q_- ;_`..-_..Found -- ation :�-o-�``1---.-..Property Line------ .�--- ----.. ---- f Depth..--- �HPre#Q _�r1Bir --. - .0-..-.Number.............. "�` _.--____ Rock Filled Yes ellNo Water Table Depth------------------240--f''--------------------- -- .Rock Size----- ------------------------ Distance to nearest: Well.-----------IP—A4--------------Foundation..----.ta-.114 Prop. Line-... _ -------- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date----------------------._.-------.------------- ) SepticTank (Specify Requirements)-------------------------------------------------------------------------------------------------------------- ----------------------------------------- DisposalField (Specify Requirements)---------------------- ------ --------- ---- ---- --------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- - - r i {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 Coun Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agent 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-I=------ -------------------- Owner By------------------------------------- - Title (If other than owner) FOR PfPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------- ---- - ----------------------------------------------------------DATE./.Z- b' ------------------- DIVISION OF LAND NUMBER.-- ------------- ------------------------------------------------- -------.DATE------- ---------------------------------------- ADDITIONALCOMMENTS------------------------------------------------------------------ ---------------------- ------------------------------------------------------------------------------. ----------------------------------------------------------------- ------- --------------------------------------- --- --------------------------------------- --------- -------------- --- ----------- -- --- ------------- -------------------- - --------------==---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ - - --- - ---------------------- ---------------------------------------- ------ - - ----- Final Inspection by -- �--r- -�---- --- ---- --- ------------------------------------------------------------------------Date - eli 13 24 S JOAQWN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M