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FOR OFFICE USE: FOR OFFICE USE APPLICATION FOR SANITATION PERMIT 1,5` (Complete in Triplicate) Permit N Date Issue.-.,P/-- � ----- ........ 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 CoungjtX Ordi once No 49 and existing Rules and Regulations: JOB ADDRESS/LOCATIO 9--- -- - ----- --- ---- - ---- ---- -----------.CENSUS TRACT----................. .._ . Owner's Name.. ------ -•------.Phone----- ------------------ ............. .. ----...------.....- Address_-..': L _... City zip -= ...... ..W ----- Contractor's Name. .......... '(�' - License #--- Phone-.. -_._ �. , IX 9 Installation' will serve; Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--.-. - - Number of living units_____ __________Number of bedrooms-,03......Garbage Grinder------------Lot Size---tgri -O .X. '_P_-:-._..._ Water Supply: Public System and name------- -------- ----------------.----..........---------,-•-------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt[] Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam I Hardpan ❑ Adobe ❑ Fill Material.. .._ --- If yes, type-------------_................ 4,1: (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 TREATMENTiSize ------------------ ( ] SEPTIC TANK [ ] SizeLiquid Depth.-•-- -- -------------- ! L Capacity/. Type,---8----- tarial_--C __ No. Compartments--_ i4,---------------------- - i Distance to nearest: Vl/ell... .Foundation---------- - ------ ------Prop. Line-----------.---------..-.-. ,t LEACHING LINE j ] No. df Lines...... ...... of each dna----- .1' 7_-1.44 Total Length - _ ------------------------ ..... D' Box, pe Filter Material----- ..__ Depth Filter Material--.-� _____,.._i...--:-__.._.___....-_-- -------------- Distance to nearest: Well _., ,c :.Foundation______________________ Property Line------------- ......... SEEPAGE PIT j ] Depth.2.4..._Diameter..W----- -----Number --------� -------------- Rock Filled Ye No ❑ Water Table Depth--------------- ------•- ------------------------•----Rock Size..... •...... Distance to nearest: Well-------------------------------.. Foundation............ -- Prop, Line........................ --- REPAIR/ADDITION (Prey. Sonitation Permit#------------------------ ..._. _.__-Date_...___•_-----_---.----.-----------.---.._-_--) , Septic Tank (Specify Requirements)----------------------------------------- ....... ---------------------- Disposal Field {Specify Requirementsi_...................... . --- -- ----------------- ................................... ------ ------------------------. --------- ------------ ----- ---- -------------------------- - --- --------------.....-------- ------------- ------------------ ---------------- -------- (Draw existing and•reQired addition on reverse side) 1 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 Mules and Regulations of the Son 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 CorFroosation laws of California." Signed--- Owner By_...._ .. --. 77- ... . ...... .......Title--------......------.... ---.... --....... (If other than owner) FOR DEPARTMENT USE ONLY ll APPLICATION ACCEPTED BY -_ _ - ------ - ----- ---------------------- DATE _-..-_--.---.-.- 4 DIVISION OF LAND NUMBER.-- ......... ------- DATE----- ------------- ADDITIONAL COMMENTS---- - ------- ---------- --- - ------ i Final Inspection by:-.--1 - ---_-.---Date...-_--- -- Z- ) - ...... - ............ -------------- -- .a -... EH 13 24 SAN J0AQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M i