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FOR OFFICt USt: . FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit Na.Z? (Complete in Triplicate) ------------------------------------------------ Date issued__r.772 This Permit Expires I 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. I This application is made in compliance with County Ordinance No. 5A9 and existing Rules and Regulations: ' -��' 1 .. T°`'. CENSUS TRACT..-..-_--- ------ ....... -- JOB ADDRESS/LOCATION.......... �.-.._-..--./-t. .... r-.. Owner's Name ........... ... 1 �''" ..... Cit - - — .-& .--. ......zip---- ' Address----....------ .. y ... � , y... PF1 -- License"#- -.-::............'• one = - Contractor's Name............. Cr Installation will serve: Residence �' Apartment House ❑ Commercial ❑ Trailer Court ❑ j 1 I Motel ❑ Other- .--- --- ---------: X �y 1/`f ... i Number of living units: �------Number of bedrooms.-..a Garbage Grinder_----------Lot Size.............. Private F Water Supply: Public System and name.."---- ----------- ........ Character of soil to a depth of 3 feet; Sand ❑ Silt ❑ Clay ❑ Peat ElSandy Loam ElClay Loam 1 Hardpan E] Adobe ❑ Fill 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.[ a NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] ,, PACKAGE TREATMENT [ ] SEPTIC TANK Size.. li�-�' -------------------------- --Liquid Depth.----�6----Y -- ! ents2r" -r..No. Com Capacity.-IlO�5�TYPe.�tC"4$sfMaterial � partm dFoundation ..... ...Prop. ...--. .. LL Distance to nearest: Well------------,�e2- -..- -"- - -- ------ � � d ' Total Length .....-- v2 ......---- LEACHING LINE [� No, of Lines. ._---... .............Length of each line..----- -- - -- A 'D' Box-.--. - ..Type Filter Material.sceb,, ... Depth Filter Materiill."--------1 ----- Distance to nearest: Well_- . Q.. --- Foundation....-- Q--- Property Line.-".- - :- . �� - - Rock Filled Yes F] No C3SEEPAGE PIT [ ] Depth.- -. ":...Diameter----- ------- ----Number--- ----------------------------- ""-.- WaterTable Depth-------------------------------------------- -----------Rock Size"-.:. ......... ......-........----------------- . _ '--• - F�undation Prop. Line Distance to nearest: Well--------------- ----" --- _-. ..r.-t- — .1 ! REPAIR/ADDITION (Prev. Sanitation Permit#------------------ ------------Date..----- -- ...... ... . ] Septic Tank (Specify Requirements)-.-._ --------------------- ---- ' Disposal Field (Specify Requirements)-------------- ----- -----......... --- ------------------------------------------------------------ -----. (Draw existing and required addition on reverse side) I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County tions of the San Joaquin Local Health District. Home owner or licensed agents Ordinances, State Laws, and Rules and Regula l signature certifies the following: "I certify that in the perform nce of the work for which this permit is issued, I shall net employ any person in such manner as to be a subject to Work n's Cbmpensa 'on laws of California.' t Signed . _.. -...Owner V '". _ ... ..Title ------ ------•.....-- - -- - --- --- ---- - - ------------- (If other than owner) jqR DEPARTMENT S ONLY F -DATE ...------- - -- --- ---- ---- APPLICATION ACCEPTED BY---------- -- - .. .... .......... --- - .. . .. -.-.. DATE..... DIVISION Of LAND NUMBER-------- -- --- -- ADDITIONAL COMMENTS... r� r ---- ------ .. ...- - . ....� ...._31 ..- .--- ---- ...... ........ ----------•--:....-��----- - - ----- = _" Date...... _/_ k...- Fina! Inspection b ""-"- F65 21677 REV. 7 76 I EH 13 24 AN JOAQUIN LOCAL HEALTH DISTRICT