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_FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: '�� (Complete in Triplicate) Permit No...I-��._7~' -! --------------------- This Permit Expires I Year From Date Issued 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 �compliancewithCounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION... � T _ 'r 7CENSUS TRACT - -- --- ---------------- Owner's Name- _ IQb-. 7 - --- - --- -----Phone- Address------------ !Gl.� 2� Cit ----------------------- --------- Y Contractor's Name------- .-__-_- :. a"7rt/�..� --------------License ...... y -__ Phone_ 66'_9�P� -- Installation will serve. Residence Apartment House [❑ Commercial ❑ Trailer Court ❑ 'Motel ❑ Other' - - - - ------- Number of living units:-- -_--__--Number of bedrooms__--3 r --.Garbage Grinder------�size ----- Q----ZC -.. ��_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 seepage pit permitted if public sewer is available within 200 feet,) W PACKAGE TREATMENT ( ] SEPTIC TANK Y ------Liquid Depth.__,- -.---- v /+_ Capacity .-y( _ t-_TYPe -- ------- - --------Material--- 'f_i�_�� No. Compartments--------- ---- Distance to nearest: Well.,_-, _ : _ -_`--------------- u r __--__-Foundation-.____ �--------------Pro Line. OF LEACHING LINE No.'of Lines----------5__---__--__..Length o--f eachlinep___--._� --------------Total Length.-- _-(2_0 'D' Box__ - ---Type FilterMaterial--._ c� - Filter Material----------1 Distance to nearest: Well--.-.Sart`_"__-----Foundation.-- f DP ----_-_property Line_.---- - • « ` ----- SEEPAGE PIT Depth--- -----------Diameter - ---- Number----------- ------------------- Rock Filled YesXK No ❑ Water Table Depth- -•----------------- Rock Size- Distance ize Distance to nearest; Well__-.-- _---_-----_-_--Foundation------- _b T------- Prop. Line_Z71_ -------------- REPAIR/ADDITION (Prev. Sanitation Permit#------------- ----_-Date--.--___---_ ------------------------------- Septic Tank (Specify Requirements)------------------------ Disposal Field (Specify Requirements).____________________ --_-:` ti -------------------- -------------- ---------- ---- ------------ - -----------------------------------------------------------------_-------------- - ---------------------------- (Draw existing and required addition on reverse side) - I hereby certify that 1 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 awrier 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;em to to become subject to Workman's Compensation laws of California." p Y any person in such manner as Signed-------- - ------ - ------ Owner ------ 11, BY - - �- --Title ---------- --- - ---------------- t er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----r__- ?41 DATA_.--------7f Q- DIVISION OF LAND NUMBER-----------------_---_ - DATE-------- --- ------------------------------ ------------------------ IONAL COMMENTS--._----__-_.___-_ --- ------------ ----------------------------- ----------------------------------------- --------------------------------------------------------- --------- " ----------------------------------------- ------------- ------ - --------- ------ Final Inspection by; ------ -----------------Date------ EH f -- 13 24 SAN JOAQUIN LOCAL EALTH DISTRICT F&s 21677 REV. 776