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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No... ....' : P ------------ ---------------------- This Permit Expires 1 Year From Date Issued Date Issued..16`].(17_�_'. 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 CountyOr ' ce No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATIO ------CENSUS TRACT..----- ---------- Owner's Name.... ... - Phone—_�I-3.54 oe...... Address..- City ----- ZiP....j........ Contractor's Name......... .. ------....--- .-•- _-------------- "License Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other... Number of living units:------./.....Number of bedrooms...0. .Garbage Grinder------------Lot Size.-' . Water Supply: Public System and name------------------------ Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peaf❑ Sandy Loam [] Clay Loam a Hardpan ❑ Adobe YFill Material.. ..-. ... If yes, type....... ........................ (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 or seepage pit permitted if public sewer is available within 200 feet,] . PACKAGE TREATMENT [ ] SEPTIC TANK [ 1 Size-------- --------------------------------...----------_--Liquid Depth--------------------------- Capacity.. -.----..-..--------- . Capacity Type Material-_-" - _-----------------No. Compartments................ ................ •u^ Distance to nearest: Well.......................... .... ......._Foundation.—... .... .............Prop. Line...................-...... LEACHING LINE [ ] No. of Lines------- -------------------.-Length of each line -------------Total Length .. .....................-...--- - t` 'D' Box--------.---Type Filter Material.......-.......----.Depth Filter Material--------..•_........--------------------------""-----"--------• w Distance.to nearest: Well............................Foundation............................Property Line-_..--------._.---..------........ , SEEPAGE PIT [ ] Depth....-- ....Diameter........•--- Number----------- ------------------- Rock Filled 'Yes ❑ No❑ Water Table Depth----------------------•---------------------------------.Rock Size--.----... -- ----- ...----- Distance to nearest: Well-------------------------------------------Foundation-------------- -------.--.Prop. Line---.---------------------- REPAIR/ADDITION-(Prey. Sanitation Permit#------------------........".............:..........Date--------_..---------.---..----.-------.------1 Septic Tank (Specify Requirements)-- ---- --- - --------------- �/ 1 Disposal Field (Specify Requirements)-- ---,4w- _- iL/_ - - --------- . .. ----------------------------------- ----------------- ------------------------------ ---......-•---•... -"".... . -----4;Z ---------- (Draw existing and required ddition on reverse side[ I hereby certify that I 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 thework r which this permit is issued, I shall not employ any person in such manner as to become subject to rk n's C ens laws of California." Signed... -------- " --11-- • ----- - .Owner By....... other s ... ...Title. s--------------------- -n(yo owner(I ..... .- FO DEPART EN LY APPLICATION ACCEPTED BY--- ....... . ------ DATE �! DIVISION OF LAND NUMBER..... DATE. - --------------------------------------- ADDITIONAL COMMENTS------- -------------------- -----�= -3---- t;, --------------- ---_-_- ----- ----- ---------.----- .. ------.- - ------ --_-- - -- - ._.. Final Inspecfton b --------------------------------Dote.--------'.r r� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6$21677 REV. 7/76 3M