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FOR OFFICE USE: -FOR OFFICE USE: ✓ APPLICATION FOR SANITATION PERMIT i.. r Permit No.: ,, r,� (Complete in Triplicate] � ------- --------------------- -------- - ------- ----------- -- " k .�� pp 6 �� Date Issued --- _--i__-".- 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 Ordinanc .No. 549 and existing Rules and Regulations: �^ -- ------- TRACT.---------- -- -------- ------- CENSUS JOB ADDRESS/LOCATON___------------ "-- .-.-----• E ------- Phone- 7- Owner's Na e. "_-. __... ° - -- - ------- - - U ity -------- - ----zip . a Address_ = ---- - --. _ C i '.. .. � _ License #_.��.-_�_./__:---Phone._--� --- - Contractor"s Name _- = - = sK. t" Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ . _. . ._:. Motel ------------- ---=-- =--- --- -- --- . t ' -------Garbage Grinder---.=-.-- -Lot Size--- .---------- Number of living.units______ Number of.bedrooms:_' Water Supply: Public Sysfiem'and name-.: _ _'-------------=-- --- ----- G - Private x e Character of soil to a depth of 3 feet: Sand ❑ ISilt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe ❑' Fill Material-----------_If yes, type-------___.__.____------___--_. (Plot plan, system in relation #o;wells, buildings, etc. must be placed on reverse side.) showing size of lot, location 04 NEW INSTALLATION: INo septic tank .or seepage pit permitted if public sewer is/available within 200 feet,} ' / ----------- fill _ / U-'----------------Liquid Depth------- TREATMENT• ( ] SEPTIC TANK YPF . Size= 'I; µ_No. Compartments--------------- ------ -----= - Capacit .60..4)_-----T e-�/iiFC-._ -Mateaial_ Distance to nearest: W -------------------- ------Foundation-./ ------------Prop, Line---r�„-- -- -"--- - LEACI ING LINE No. of Lines_'__ .._-_,Length of each ling..' �_.`0-g0---f/---.Total Length --.__,�a - -,-;--- D' l3ox__. -_Type Filter Material 5I �t�' Depth Filter Material_____-��----11-----------I------ ----- 1 t ` Foundation_--- -- _ Pro er Line_- -- f--- Distance to nearest: WeIL•_�4 _.____.__-- -------------- P t SEEPAGE PIT Depth__ .- *--Diameter__. ___Number_-----_�----------------=- Rock Filled Yes No '4 f' K ' Rock ize � �3 ----- - 1 � Water Table Depth-- f-�'�---=-----� "--------- ---------------Rv � - ---------� ----------- � . . . Distance.to nearest: Well_-.,�_ -d__- --------`- ------Foundation______ �U-------- -.Prop• Line- --- _--- - {.,-_ i .. . .-------Date'------ ------------ -- REPAIR/ADDITION (Prev. Sanitation Permit ----•:----- -------- P (Specify. q -------------------=---------------- ---- - -------- Septic ------- i Se tic Tank S ecif Requirements) Disposal Field (Specify Requirements)---=------------------ --------- -------- ----- # ' --------- ------------------ f -------------------------- -------------- :..-. -- --- --------- ------- --------- ----------- - t ------------- ------ ------ --=- ----- -----------------------------------------------------_----------------:- -------- _-- �. {Draw existing and required addition on reverse side} "- INhe'reby certify that I have prepared this application-.dnd that the 'work will- -be done in accordance with-�Sdn-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: y ' "I certify that in 'the performance of the work for which this permit is issu d, I shall not employ any person in such manner as .to becom bje t to Wor an as. ompensation laws of California.” ----- A --------------Owner . ... Signed --------- t. 6 4 -- - - - -- - > ------------ Title ---:---- ' -- --'--------------------- BY-;------ llFoter than owner} ` +-' FOR DEPARTMENT USE ONLY: " APPLICATION ACCEPTED BY____': DATE. Z ---------- ------------ DIVISION OF LAND NUMBER------------------------------------------ DATE - ADDITIONALCOMMENTS.-'---'-- D----------- -------.- -- ------------------------------ ----------------------------------------- -------------------- ----- ------------------ - = ------------ ------------------------------------------- :_ " Y ��- / ----- ---------- ------------------------- - --------------------- ---- 1 $ __________-______ __________ ______ _______________ ---------_____ P ----._-- -,,�.' Date--- _ --- Final Inspection by; -------------------------------- ----- F85 21677 REV. 7/76 3M EH 13 24 SAN JO UIN LOCAL HEALTH DISTRICT