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FOR OFFICE USE: FOR OFFICE USE * APPLICATION FOR SANITATION PERMIT ------------------------------------------ ---- (Complete in Triplicate) Permit No.._7..__�_.7 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/LOCATIO __-`�` k- 74__x` � t.- ' ---- � ------ --W-- CENSUS TRACT-------1:,--- - - Owner's Name - 4 ----------------------- - --- ------ ` . � ,�- ��. � �.:.� - �__. T ..Phone Address-.. 1'- f �'-r,��y ,---------------------CitY ---------------------- 01 ------------ Zip 1�= a d� A, Contractor's Name_ � c__�� License #. T ---Phone-9 Installation will serve: esidence�' Apartment House❑ Commercial E] Trailer Court-[]- Motel-F-1 Other---------------------------------t--:-------- ; Number of living units:-------- ------Number of bedrooms-_//-----Garbage F ' Grinder-__._f-r-_LotSizes----------------------------------------------------------- 4— ________________________-.____-____-.._. ?- _PrivateWaterSupply: Public System and name______________ .__.___._.___ f__.____.--------------------------------------' __ _--_--- Chardcer � of soil to a depth of 3 feet: Sand ❑ _ Silt❑ Clay [}-G.P t 0 Sandy Loam ❑ Clay Loom;e— Hardpan ❑ Adobe []- Fill Material._::-------If yes, (Plot*plan, showing size of lot, location of system in relation to,wells;-buildings, etc. mustbe placed on reverse side.) a NEW INSTALLATION: ]No septic tank or seepage it p-ermitted if public sewer is a a fable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ,I Size-----__ -- I'-----------------Liquid Depth---------------------------- Ca p acit a-- Material __ Com artments------` ----- 1 'p �i� ________________ ._l Distance to nearest: Well-- eA- ----- 7: -- ,.-. _rFoundatfon--- � ________Prop. Line___✓L_ __ LINE [ ] No. of Lines.-__)7 ------ ------------ Length of each line.______-__..___.____.Total Length _ ,�. ------------------------ LEACHING ' D' Box---- ------Type Filter Material___ __Depth Filter Material---2 '--/_---------- -------------------. Distance to nearest: Well----------------------------Foundation----------------------------Property Line_------ --------------------- . SEEPAGE PIT [ ] Depth----------------Diameter..._-----------------Number-------------------------------- Rock Filled Yes EJ - No ❑ Water Table Depth--------- ?---------------------------------------------Rock Size---- --- ----- ------------- Distance to nearest: Well._;------------------------------------------Foundation--------------------------Prop, Line---------------------------- REPAIR/ADDITION (Prev. Sanitation Permit#____ ---------------------------------------------_Date-_-..._-...-____-____--._-_____-_-_-.-_.] SepticTank (Specify Requirements)--------------------------------------------------------------------------------•------------------------- ----------------------------------------------- Disposal Field (Specify Requirements)-------------------- -------------- ----------------------------------------------- ----------- 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: "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." AJ`3 Signed � -.-f---,-L - -------------- --- --- --------- -----------------------Owner By--------------------- ------------------------------------------------ -------------- --Title----------------- ------------------- - {If other than owner) FOR DEPARTMENT ONLY APPLICATION ACCEPTED BY - --_. __---__.DATE . .__._� J DIVISION OF LAND NUMBER-------------------- -DATE--------- COMMENTS ---------- ----- --------- --- ---------- ------------ -------------------- ---------------------•-------------------------------- ------------------------------------ - - ---- --- ---------------------------------------------- ------- ------ Final Inspection by -- --Date- .__ ___.. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7176 3M