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f v ++ FOR OFFICE USE: _ 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in,Triplicate) Permit --------------------------------------------------------- / , ------- This Permit Expires 1 Year From Dolte 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 compliance with County dinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT,ION_...le --__ ,__ CENSUS TRACT`-".-_____- -- --- - Owner's Name Q �� ------Phone------ — _. __ Address__-_ _ j----- ._City---- ------------------- -------------Zi �S �< l'------ -- Contractor's Name_ P '__ ---_----------License #.ft50�S;p .." Phone Mc:3 '- Installation will serve: Residence R4- Apartment House.ECommercial ❑ Trailer Court ❑ h Motel ❑ Other- ,w'= — _ I I � Number of living units:---------------- f ____-__Number of bedrooms_:-___._Garbo a Grinder---- Size._._ Water Supply: Public System and name---------------------------" 1 l '___--+#- Private � ------------------------ =---------------:_------------ � ( - - it � . Character of soil to a depth of 3 feet: Sand E] Silt El Pay E] Peat ❑ Sandy Loam [,cam 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 pi ed on reverse'side.) 'Y NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avdiidile'withiri:200'feet)= PACKAGE TREATMENT [ ] SEPTIC TANK Size__ ►"_ � Liquid Depth "�`"/ �r --- --- Ca acit 6d2 ; ~ P Y- -----"Type- -- ----------------Material_--�o------No. Compartments-----_-- Q------------------ Distance to nearest: Well------- ._ _-__-_�- - ».:__,. _,Found_ation_ _ ._- "".""_-Prop. Line___/ _ --"" LEACHING LINE [ ] No. of Lines.__. _______________ each Length of h lina-------7�._.�- Total Length. --� � � / � // ---------. > ---l��------- --- ----------- 'D' Box_` _ Type Filter Materialf.�'�`��--Depth Filter Material----�X.Z-.�_ r \�� = = -- -------------- tl Distance to nearest: Well--- --------------------Foundation__ _Property(Line_ _____ __ _ O IT [ ] Depth-- o - Diameter. .--"--- _--Number--------�------------- Rock lifled1/Yes4;- fVo[] Water Table-Depth ------------------------------- p ---: Rock Distance to nearest: Well_ ---- - Foundation _. _ i_.Prop. e --------- ( vSanitation onPermit# ------------------------------------ ---------. .---------- - Septic Tank (SpecifyRequirements) - - -- -----' -------Y ^_______________________________".:------------------- "------ = - Disposal Field (Specify Requirements)______________________ " ' --------------- m - - - - ---------------------------------------- --------- I -- - --------------------- __ --------------------------------------- --------I--------------------- _ __-_.____-_____________.____ .--_.._______"__._______.____.______--__._._____--_-.____-- (Draw existing and required addition on reverse side)l �1 . I hereby certify that I have prepared this application,and that the work will'fbe done in accordai ce 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: t "I certifythat in 'the i - performance of the work for which this permit'is issued,'I shall no't'employ any person in such manner as to become subject to Work Gin's Compensation laws of California." Signed---------- --- -------------- - -- - --------- ----------------------------- ------------Owner y -- - ------ - -- -- --- -----Title----- -- ------------- - -------- --- (if other thari owner) ,FOR DEPARTMENT USE ONLY APPLICATIO�AE PTEDBY ----- --------------- ------DATE.--- -DIVISION ONUMBER DATE _ - ------------------ ADDITIONAL COMMENTS------ ---------------------- ----------:---------- ------------------------------=---------- ------------- = - ------------------------------------------------------------------------------------------- ------------ 9- ------- - --- ---- Final Inspection b �'_ Date_:_ "- . p Y= _ - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 007 F&S 21677 REV. 7/76 3M Ek