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FOR OFFICE USE: V/ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------- Permit No..29':7V" (Complete in Triplicate) --------------I------------------------ ----------------- Date Issued(/-15.:.7X --------------------------------------------------------- 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: _ --------CENSUS TRACT----�JS'3 --- - cy ti JOB ADDRESS/LOCATION.--.--- �U. -...-- -- -- ------ Owner's Name -------------- -- - - ------ - -- -- - --------:- =--------------------------------- ----- • ---------G1 • Phone.---- --------------------------------- --- ------------------------------ " tiE -------city ------------------ ----- Zip Address--------- -- --- -- -`- j OA Contractor's Name--------- ------------License # 7�Z..: ' Phone .Z ' Installation will serve: LResidence E�' Apartment House E]' Commercial ❑ Trailer Court ❑ �� .i ' Motel Other-- Number of living units:-- --------Number'of.bedrooms-."-,9U-Garbage Grinder_'. ---:-Lot Size--------:-.--.-'---------. _ r-. �"-----. Water Supply: Public System and name----------- --� ----- --- : -,r ---- ----------------------------------- -------"-Privat 1 pP Y� � e .G Character of soil to a depth of 3 feet: Sand [�� Silt ❑Clay ❑ Pea#_[� Sandy Loam ❑ Clay Loam ❑ r_-� Hardpan Adobe ❑ a, Fill Material-- --.--..__Ify�s, type---,-----_.______-.----_- . �... .�.--. -----r �- (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 o� seepage pit permitted;if public sewer is available within 200 feet,)' PACKAGE TREATMENT [ ] SEPTIC TANK' [ ] Size -----------Liquid Depth-___________________ -----' -- -------------- ' __�_+ al = ` ! �_.---No. Compartments----------------------------------- Distance -- ) - Ca acit -.-Type ------- ----Mdtori,.... ------------------------ LEACHING , Di sante to nearest: Well,...- _.___Foundation----------- ----------------Prop. Line---------___-.-----.--- LEACHING LINE [ ] No. of Lines-=--- --" :- Length ofieach.line-------_7--------------------Total Length.-- : _1------------------------- 'D' Box------------Type Filter Material.......:..... t_-Depth Filter Material-------------------.---- .t ------:----------------------------s ---- -----------------Distanceto nearest: Well-=------------------- --- Foundation---= ---.Property Line SEEPAGE PIT [ ] Depth----=----- ----Diameter.-:------------- ----Number_-',. -------_------------.--_ Rock Filled Yes-E] No E] (Nater Table'Depth. = Rock Size ----- =-- --------- ( Distance to nearest: Well-=---------------------------=---------- -- P- - � --Foundation------- -- -- - ----Pro Line ---------------- '- REPAIR/ADDITION (Prey:Sanitation Permit#-.--- _' 3<<' -------=-------Date- -r__ Septic Tank'(SpecifyRequirements)------------------ ----- -----------,--------- --------•--------.:, Disposal Field -------- (Specify.Requir.ements)------- ------------ ----------------------------�---------------------�------- ------------ ----�--------------•----- -} �------ - Y -- : . ,-` ------------------------------------ ----- -------------- (Draw existing and required addition on reverse side) M II hereby certify that'l 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,'.' Signed-: ---- - - ..-----`------=--- Owner BY- ------r---------------------------------------- -t - - k (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED-BY - = - --- -------- ° :---- ---- --------------------------DATE.-- ------ ---------- DIVISION OF LAND NUMBER.--------"------------ ------------------ ------- •-------- DATE ADDITIONALCOMMENTS------- - ----------, ------------ ----------------------------------------------------------- ------------------------------ ---------------- -------------------------------------------------------------------- ------------------------------------------ --------- ----------------------- --:---- ------------------------------- ------- -------r------ - ---- _-- ------ ----------------- - --- -- - "---- -- ---- -- FBS 21677 REV. 7/76 3MFinal Inspection by - -----------Date.- EH 13 24 SAN JOAQUIN LOCAL H TH DISTRICT