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�) T FOR OFFICE USE: �l FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - F Permit ------ ------------- ----^ - -,----. (Complete in Triplicate) ------------------------------ g Date Issued- ,,-- -------- -------f5------- ------------------------ -------------.5---------------..-_-___-__-_. -- 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/LOC ION .-_ "` - ---- 11d�5----------- -- --- ------ --- -----=------ ----------- - ---- ----.CENSUS TRACT -•----------------. -----.. Phone.I-..--.---,-----------Owner's Name `fIT��-- .- �j Address----- /pi� -----M1-- ------- .;.:- :.:{ -------_--------.�-------- --city r Zip :: Contractor's Name Phone µ --------- - -- # License Installation:will serve: Residence 2r Apartment-House.❑ Commercial ❑ ;Trailer Court ❑ Number of N. :, rK• �.Motel ❑ Other =- ---- 4 n } ,_ i living units:__:_ '1. o#"_____Numberr :bedrooms ��Garbage.Grinder Lot Size" ___. Water Supply: Public System and name--------- ----- --------------------------- - .,,,Privr Character of soil to a depth of 3 fee,�t�,:` Sand ❑ Sufi❑,aClay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan Ld. Adobe❑ Fill-Material----- if yes, type------------- El ---------------.-- R , (Plot plan, showing size of loft, location of;system in relation to wells, buildings,letc. must be placed on reverse;side.) +� NEW INSTALLATION: P �JN0 se tic tank 'or seep ge pit permitted i public sewer is available within 200 feet,] Q ' PACKAGE TREATMENT [ J SEPTIC TANK"[ --- --- Liquid Depth----./ _-_- Ca pcity.� gid_-.___ Type .Material_-( � -- -- -No. Compartments----- --------r------___-- p / •--- Dista ----Foundation- ---:-- --Pro Line.... -------------- nce.to nearest: Wel I:.._- -----;-- P LEACHING LINE [� No. of Lines-.=.--------7—' ----....'Length of each line-.-;---,,: --------=- Total Length.--- .------------------------- -- D' Box---'/-----:Type Filter Material:------ 5__P__---Depth Filter Material-,--,---.:-/ ----------------- -- - 'Distance to nearest: Well. --------Foundation---------& -.Property Line_-'--- __ ___��4 SEEPAGE PIT [ Depth _ ameter-'j- --- --Number_-- ----- ---- --- Rock Filled Yeso ❑ Water Table Dept --- c iz - ----------------------- ------------ p�-- Ro k S e- ... , . Distance#o nearest: Well._:__ Foundation__��?_�9`_____..Prop. Line_ ;!. REPAIR/ADDITION (Prev. Sanitation Per mit'#_. ----- ----------------------------------------Date--------------- .---------------- 1 t SepticTank (Specify Requirements)----- -------------------------------------- -------------------------------------------------------------------------- --------- !'. �r Disposal Field (Specify Requirements)-..-__f` ------- ----------------- -------------- ---------- -------------- ------------------------------------------------------ ...... --- -----=--------------- --------- a. -- -------------- -- ---- ---- ----------------------------------- --------------------- ----(Draw------existingand required ------------ - �,.. q red 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 Sari Joaquin Local Health District. Home owner or licensed agents signature certifies the following: i } "I certify that in the perforins anteof 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." NSigned a Owner : . _ ----- --- ---------- ------- . By-- - --------------- -- - -- Title (If"other than_owres i „ '^ FOR"DEPARTMENTUS ONLY ► ._ APPLICATION ACCEPTED BY'ri, 3"- = DATE. DIVISION OF LAND NUMBER: -- s .. - " "'"- .DATE- ---:---- ADDITIONAL COMMENTS--- -------------- --------------------- --------------- .----- - ---------------------- ----------------- --------------- ---------------- - ------------=--------- --------- --------- - -------- 'i. ----------------- --------- - - --- j --- ---------------- -------------------- -- ----------------------------------------- _. _.- DFinal Inspection by ---------- ate---- -- ---- EH 13 24 �� SAN JOA 1N LOCAL HEALTH DISTRICT F&s 91677 Rev. 7/76 3M