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FOR OFFICE USE: - FOR OFFICE USt: APPLICATION FOR SANITATION PERMIT ........................... (Complete in Triplicate) Permit ---------- This Permit Expires 1 Year From Date Issued Date Issued.-5.__0. 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 compliion_ce.with County Ordinance No. 549 and existing Rules and Regulations:. p" J JOB ADDRESS/LOCATION --•---- .lc - :..a .. �i _ - CENSUS TRACT g--.... - Owner's Name..........70-y±0✓<. G�� ------------- ----------.............. --.-......------Phone_ Address............. - / / • ...... ..--------- Contractor's Name-------- ------------- - -.License #c��J-�'�..��....Phone. .:- --�- ---------� Installation will serve; Residence. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other....... ......... ------- ------ Number of living units:.- ............Number of bedrooms..[.... Garbage Grinder-------- ...Lot Size....-....J?.-`�..— ..-----"--"-- - -- -,� ---Private Water Supply: Public System and;name------- -----------------------------------------------------------------------------...................... - - ---------- ------ Character of soil to a depth of 3 feet:" Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy?Loam Z day Loam E!. f Hardpan ❑ Adobe❑ Fill Material-- .-- ----If yes, type............_.°.................... . k (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must*be placed on reverse side.) g.) 4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ( j .Size....._ .. - Lam--- ------- -----Liquid Depth."'..,- ... Capaci:Y,1O'`.�`0- -----Type / .�r� .Material No. Com artments.. # Distance to nearest: Well-:._..C" .-- 'A1 p. -�� LEACHING �ndation..-- f� _•...-..- 9-Pro Line---- --------... LINE [ ] No. of Lines......._.---.-_-....Length of each%ina---- .�..� �-- Total Len�.......�.��. al Type � . epth Filter Material- 1---------- ------------- --- 'D' Box.. .. _.__...T a Filter Material../�___.../� Distance to nearest: Well--- .......... Foundation.....G?.-.11-- .......Property Line.;11�$-—.... ......:.._._.. . SEEPAGE PIT [ ] Depth.......... .....Diameter---------------- Number....-----------.----------------Nsy Rock Filled Yes ❑ No Water Table Depth.--------- ------ ---------------------Fo._Rock dot o'ne... i Distance to nearest: Well- .............. .... ........._.Prop. Line... REPAIR/ADDITION (Prev. Sanitation Permit#............ . Date-------• - -----. Septic Tank (Specify Requirements)...... )%ieA ] Disposal Field {Specify Requirerimentsl ---------• '. „ r y ...................... ............. - ...... ............_-.................... �V ------------------- i ....................... ------ :.............. -.. ........ (Draw existing and require!additidxi dh'reverse side) , li I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j Ordinances; State Laws, and Rules and Regulations of the San JoaquinI local Healfh'District', Home owner or licensed agents i signature certifies the following: "I certify " that in theperformance of the work for which this permit is issued; l shall not employ any person in such manner as - to become su ect to o an's Co.rnpensation laws of California." ` Signed. --- -- Clwner i BY-•-------------- . ------------------------- .Title--- f------------ (If other than owner[ �. FOR DEPARTMENT USE ONLY ► f _ APPLICATION ACCEPTED BY - ------- DA .... .........DATE . C DIVISION OF LAND NUMBER:..:?:.,: :_-.:,. '=:----- DATE - ° _ = = ADDITIONAL COMMENTS------- ----------- .. -------------- -- ` _ ................... ---- ... - . - ----- ---- ------ ------------------ - - 1 Final Inspection by: ..... ---------------- ---........ --------------------•. ....Date.....------------- ' EH 13 24 SAN JOAO IN LOCAL HEALTH DISTRICT Fos sie77 REV. 7/76 3M �r y .