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FOR OFFICE USE: FOft'OFFICE USE: APPLICATION FOR SANITATION PERMIT C_ /7/4;/7/4;7 Permit No... --- .......... )Complete in Triplicate) ---------- •--------.................•----- Date lssued.... ...--- ......... .................................. ................. This Permit Expires 1 Year From Date Issued Application is hereby made to.the.San Joaquin Local,HealtH.District.for a°permit to construct arid,install the-work herein described. This application is-made in compliance with,County•Ordiiiarice No"549 and istiVRulend Regulations: JOB ADDRESS/LOCATION. .. 1d .. ----.. - CENSUS TRACT Owner's Name_.._._..... = Phone •.. Address f :.: : ...__... License #... .. (� Phone Contractor's City Contractor's Name.......... 3 Phon Installation will ommercial Trailer Court ❑ serve: Residence Apartment Otlier ❑- - ----.-.^.- ----1__-.__ . P rt C House Number of bedrooms... Number of living units:......-------- Garbage Grinder-----------.Lot Size.....- .... Water Supply: Public System and name-- ---- ---------- - - - _---------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan El Adobe❑""Fill Miaterial.""" `If yes, type--------------- : {Plot plan, showing size of lot, location of system.!n relation to wells, buildings, etc, must be placed on reverse side.} NEW INSTALLATION: (No septic to or seepage pit permitted if p ser is available within 200 feet,] , �y Liquid Depth.... PACKAGE TREATMENT [ j SEPTIC TANK [ ] '' Size.--� _��I�s�-• �-fir--------------- -.. q -'�`� i -45R-------------- p � . 0 No. Compartments M -Faundatioi--�---- ....- ...Prop. --------- DistanceLine-... to nearest: We'll......../.P.V = . --- �---- --- - LEACHING LINE (. ] No. of Lines .. .---...:f...:,:',_.:-Length..o.f.,each_1ine-------.Q --.---Total Length .... D' Box. _ ... _:Type Filter Matelrial..._./._. Depth Filter Material.. --. .-- �. ---- Property Line....-----•- ----------------- Distance to nearest: Well--_�_-?._.._.. Foundation----------- ------ i v ---------------------- Rock Filled Yes No SEEPAGE PIT { ] Depth -,. De th....19-4- --Diameter....- Water Table Depth------- w_ = ----- ------------------------- -----.Rock Size �...! - 4- t[ ..._... Distance to nearest: Well.-------'----------- ------------ ..... Foundation on.... .. ......... .....Prop. Line ----------... -------- t REPAIR/ADDITION Prev, Sanitation Permit#..... ----------------- t Date.--.-- ------1 .... ----- Septic Tank (Specify Requirements)-- - ---- ............. Disposal Field (Specify Requirements).......--............ 1 7 1 s ' •FR .......... . ...................................................... . .... --- . y ------------------------- (Draw existingand req uired addition 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 the work for which this permit is issued, l shall not employ any person in such manner as to become subject to Workman's Compensatioin laws of California." - = Owne Signed....- ------ -------------•------- ....-- ---------- ....._-- Title-_.. ------ ------------- -- ----- R (If other than owner) l F R DEP TMENT US ONLY I DATE - l t ' 7.8.. ....... ...... APPLICATION ACCEPTED BY..------ °` ............. - DIVISIONOF LAND NUMBER........ .......... ------ ---------- ------- --- .....-------------------- . .----..--- ...DATE -- -- --------- ...... - -- --- ..._. k ADDITIONAL COMMENTS-- ----- ------------ -------- ...... ........... .......... ....... :....- `"-:------ � - -------- ----------••----:-:I----------- y- f ,� // —_�-...----- Final Inspection b --- ---- ---------- --- ----------------------------- Rate. y:. .__.... . F6S 21877 REV. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT