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FOR OFFICE USE: FOR OFFICE USE: '• APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No..7....- 3 Date Issued. �y-✓ _ ................... ....... .......................... 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; y��Q . ...CENSUS TRACT.---.--- ---.-. JOB ADDRESS/LOCATION.---....-•--- �-.. -/Jria"'"..... .�_-�"---.-----------------------•------••----- - �?:--...---- Owner's Name. .' ........................ ..... .. .. ------------.Phone.._.....--- :: r Address--- -- -----�. Gt• .er.�+ Cit Zi - Contractor's Name...... u---------........_- License #.. Phone. :.. ----- _ Installation will serve: Residence Apartment Haus ❑ Com rci Trailer Court ❑ Motel ❑ Other... ......._. ----- . .. Number of living units:..-.-/---.-----Number of bedrooms....A....Garbage rinder_......--..lot Size.......5... '........................... ,._._.-..- Water Supply. Public System and name.. •---- ... -•-• -- :.. :._..-..-Private ga Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ q.,g] Peat [� Sandy Loam ay Loam ❑ Hardpan f Adobe ❑ Fill Material.. .... .. .lf yes, type.............._-....._ ---- >: (Plot plan, showing size of lot, location of system in relation to well's, buildings, etc. must belecwithin ced on reverse side.) NEW INSTALLATION: (No septic tank or seepage permitted public sewer is avail 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size..... l -.----Liquid Depth.... ------ Capacity/ U ..._----Ty e ....Mat ial1 ............ .No. Compartments.....-,- -- -- -- .. Distance to nearest: We,._- � p. ..............` Foundatio .. 0- Pro Line " ....:- LEACHING LINE ' g �1 g /GQ� [ No. of Lines------------------.---= .-. Length of ch .fine..-- -- ..-•-: Total Len thy_.--.-- -•------......------.-.-- D' Box. a°'...Type Filter Material '� '...:--..Depth Filter aterial...l Q-��----- ---------------_......... ...... Distance,to asr W . - - ....Property Line-------------- ----- - SEEPAGE PIT [ ] Depth _....-- .....Diameter---- -------------Number-------------.--. -----------_. Rock Filled Yes ❑ r No ❑ Water Table Depth---------------------- -------- --------------------:-- ock Size.- Distance to nearest: Well.'.----------- ----------------------------.F undation...-.- Prop. Line.._.......---.- -- ` REPAIR/ADDITION (Prev, Sanitation Perm.it#..-_. ^�'r" .. .-..... ate....................._--...._____------ --- ----------- Septic Tank (Specify Requirements)---- ------- --- ----- -•:----------- .-------- --•--------. ----- ----.................-------- --- -----. - -------- ----- ! Disposal Field (Specify Requirements)_._.._--------------- • ._ -------------- ....................._..----------.._.-.-..................l ��---------------- _...._------ _... ............---......-_..-.-__-----...............................-------11------------._-.._.- Draw a fisting and required dition on reverse side) I hereby certify that I have prepared this pp•ication and that the ork will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and ulations of the S 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 p mit is issued, I shall not employ any person in such manner as to become subject to Work an's Com ensation laws of Cal arnia." Signed.........G.... ...... --------------- Owner BY /�,K ' ------------- ------------------..Title ...----........... ........ ............... ---- {Iothe�an o ;her FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ---......DATE . "/� •'' ' ................. DIVISION OF LAND NUMBER........................................... ...........DATE------------------- ......................... ADDITIONAL COMMENTS--------------- ----- -- --------------------------------- --- -- -._,.. ---------------- ---------------------------------------------------- ----------------,7---- ---....... Final Inspeciion bY:----- ----------------------------------------------------_-------- ---- •------ -----------------------• -----------._Date --- ------ . --- ........ eN 13 24 SAN JOAQUIN L C L HEALTH DISTRICT Fes 21677 Rev. 7/76 3M