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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- - - ---------------------- --------------------------- (Complete in Triplicate} Permit No.-_7.7---7___-__ --------------------------------------------------------- Date Issued--- -------------- ------ ---------------------------- ------ ssued_._____________________________________________________-.__ 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: li JOB ADDRESSAOCATIO � ` _ CENSUS TRACT Owe s Name - � --- fC�G.A--�l�.� - ---------------Phone------ ---- -------------------------- Address--.-.- -------- Contras# �� Cit �4` - Y Zip ress ----------------------- Contractor's Name------- ------ ---------- License #- rZ -Z Phone--------------------------------- --. __--_.--- - r Installation will serve: Residence [� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------------------- ---------------- \(� of living units _____Number of bedrooms_.__ ___Garbage Grinder------------Lot Size _ _ �_ O_ -_a --F, Water Supply: Public System and name---------------------- - _______________________________Private er of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑Y' -Peat-❑ Sandy Loam ❑ Clay Loam El{ Hardpan [Pf Adobe E] 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 SEPTIC TANK '-- --A �___-__-_-____--_____Liquid Depth__________________-__--- [ ] [ ] Size, _ p Capacity---------------------Type------------------- -yMaterial-- ------------- Distance ------- ~ No. Compartments Distance to nearest: Well-------------------------------------------Foundation --.. ------------------Prop. Line-------------------- ----- LEACHING LINE [ j Na. of Lines__--------- - Length of each line,_ _ ________________Total_Lengt>, -__,_______--_____- D' Box-----------.Type Filter Material----------- --- Depth Filter'Material---_---_-...-------.-,-_------------------------------------ Distance to nearest: Well----------------------------Foundation'----------------------------Property Line------------------------------------ SEEPAGE PIT [ ] Depth----------------Diameter-------------------_NumESer-------- Rock_�_-________ __�__ Filled Yes EJ No F]Water Table Depth--------------- ------------------ ------—.------.Rock Size------------------------------------------------ Distance to nearest: Well. ------------------ ---- oundaon------------------------- Prop. Line--------------------------- — - Foundation_ , REPAIR/,ADDITION (Prey. Sanitation Permit#-----------------------------------_-_--..----------Dafe_""1--------------------------------.-.-----) Septic Tank (Specify Requirements)----------' - - 6ry Di os'I Field (Specify Requirements) r�-n.-_ .-__-.__ r_-_-_ _-____ r- �T ------ILP--C------- R��^� 4 ``'`E - .04 _________ ____________ _ ______ _ ----- .- - -----------�.~___-- _-^ ___ -__-___-.-------_ _ ---__ -_--__.._--__-_--__-___-____-_-________.___.______._-____ 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 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: 1 "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." 7 Signed-'--------- -- = ---- -------------- - --- - ------x---------- _ ------ =Owner ---------------------- B '- - '----- -Title--- ------------------ (If ` r- - (If other than owner) 44 O DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ------------------DATE-----e 23-'- ? ? -- DIVISION OF LAND NUMBER_............... -__.DATE------.------------- - ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------------------------- ------- -------------------------- Final fn.---------------------- ------------ --- -- - ------------------------------ - -- ------------------- ------------- --------- ------------ spection by:. �2 �-------------------- ---------- -- ---------- -Date----- 9 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M