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FOR OFFICE USE: y FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------- ---------------------------------------- - (Camplete in Triplicate) Permit No._,79 _11.1.7 -------------- ------------------------------------------ Date ----------------- --- ----------------------------------- 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 TRACTJOB ADDRESS/LOCATION � � - - -------- Owner's - - Owner's Name ?-------------------- ---- ._-_ Address_ - ...... ------------------ -- F =- - ---- �'� «` `'' .City G` Zip Contractor's Name--- ---- License # - __, . _ Phone-` -- --fj._. f Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ 3 Motel F. Other--------------------- ------------------------ Number --------------------Number of living units;-IrN'umber of bedrooms_,_._ Garba e.Grindev'-------- -Lot Size_._____I---______,.�"�" " Water Supply: Public System and name----------- ------------------------------- ----------- -=--- -------- .. -----------;------------------- Private Ir Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Not E] Sandy Loam E] Clay Loam Hardpan E] Adobe E] Fill Material-!---------If yes, type------------------------------ - I , i (Plot plan, showing size of lot, location of system in relation to wells buildings, etc. must be placed on reverse side.) } r L!1 NEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) •Z P - €�l .F PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size , C '��---}� ]�"`�-----------------Liquid Depth..6_.�__---------_____ Ni r r- si ' f� l C Capacity s�.e TYP E = :=,.__Material ---------------------No. Compartments � -------------- T 3.1 ' Distance to nearest: Well.-- �� - g Found -- T Prop. Line - LEACHING CINE: [ ] No. of Lines.___--__. --_-_--_..___..Len th ofre_ach.Line.__. .._______________Total Length. _ - , _ _______ l 'D' Box-_ ----- --Type Filter Material/A0_f��Depth Filter Material-------6__------.---------------------------- ----- - Distance to nearest: We1177`- --_ - r -p Foundation.,,,.d-- --Property Line_.___- SEEPAGE;PIT [ ] Depth----------- ----Diameter--------------------Number--- f-------------- Rock Filled Yes ❑ No ❑ 'Water --.Rock Size---------------------- Water Table Depth------ ------------------ -------- -- ----------- ---------•---- 6 - i v Distanceito nearest: Well-'------------------- ------ ndation____ __ __----------------Prop.:Line---------------------------- f REPAIR/ADDITION (Prev. Sanitation Permit#___________------------------- ---------------- --Dote-----------------------------------------------)I, SepticTank (Specify Requirements)-===------------ - ------------------------------------------------ - -----------------------------------------------=--------------------------------- Disposal ----------- ---------Disposal Field (Specify Requ.irements)------------------- -- ---------------------------------------------------------------- --------------------------------------------------------------- 4 { ----------------------- ---------------------------- ------- --------. ------------------:-- - ---. ------------------------------------ ------------ --- ------------------------------ F k --------------------------'-------------=----------'----------------------- �-- -----------_-- `--- (Draw existing and required addition on reverse side) ; I hereby certify that'l have prepared this application and that°the work will be done in actardance with San Joaquin County t Ordinances, State Laws,v a-nds Rules and Regulations of the San Joaquin Local Health District. Home owner"or licensed agents signature certifies the following._ - a i "I certify that in the performance of the work for which this permit is issued, ,1 shall not employ any person in such manner as to become 'subject to orkm n's. Compensation laws-of California." Signed----...46i --' -7r----- �E-"�'`''' -----------------------------Owner By----------------------------------------------------- ------ = Title ------=------- ------------------ [ (If other-than"owner) [ FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY -r! �x:. - ` DATE - ----- -- =? DIVISION OF LAND NUMBER------------------------------- --------------------- --------- -------------------------------------- DATE..=. ADDITIONALCOMMENTS----------------------------------------------------------- ---- --- ---------- --------------------- ------------- ------------------- --------------------- --- -- - - ------------ -------- --------- ------------ ------- --- -------------------------------- ---------------- ----------------------------------------- ----------- ----------------------------------- --------------- -------------- ------ - --------------------------- 4�� - ------ ----------- ------ ----------------------------- -------------------- Inspection by:------ +j - Lq �.�' - ---------------Date. = —� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7176 3M