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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit --••----••-------------_-------------- - ------•----�- ._,��-� S' ............... ............. .-....-- . This Permit Expires 1 Year From Date Issued mate 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 complia�f�4_�� with�unty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION........ ---- ------••-- ------._ .....CENSUS TRACT ------------------- Owner's Name._. .I.. Phone ---• • ......... Address-,--- -/A. V [ - . � --..... itY........................ Zip-- Contractor's Name... .. . - ...... --.---..License #.�+?rJ/. .- Phone �dT.�j Installation will server Res ce Apartment House om ❑ p ❑ C mercial ❑ Trailer Court ❑ Motel ❑ Other.................... Number of living units:-.......I-----Number of bedrooms--- ._ 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 ❑ Adobe ❑ Fill Material.. .. ---.tf 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 [ ] - Size .�.. . ..L - ------------ -- - -----Liquid Depth.-�------ ------ - -�1 Capacity... - ,F�..{/--Type-,e,_--&?.............Materiol___67t - _1___ -:No. Compartments_019\ ----- . Distance to nearest: Well...-......4 -------Foundation.......... . ...... ......Prop. Line.......................... 77 LEACHING LINE j ] No, of Lines ... Length Length of each line.-.. `.. ................. Totel Length `. _.___............___..... 'D' Box.....-------Type Filter Material__.. Depth Filter Material_../Ar-............------------------------------------. Distance,to nearest: arest: Well--- .`�. Foundation......./.&.j-.__...---Property Line........-d .....-_.......... SEEPAGE PIT �5..-._Diameter...--5.i✓'!"".--_ Number- - --------- ------------------ Rock Filled Yes No ❑ Water Table Depth--------------- • -----.....---.Rock Size.......I. C . ... ..... Distance to nearest: Well------ Fou ndation.---..... .1..... .. ......Prop. Line--------------------------- �. REPAIR/ADDITION (Prev. Sanitation Permit#.-•----------------------- -- -- - ---- -_._..Date----------------------- ...-...-.. .... .-----) Septic Tank (Specify Requirements)__ _- -- ------------ --------- ----------------- Disposal Field (Specify Requirementsl.........I------------ ---------------------------------------- ----------------------------- - (Draw existing and required 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed .............Owners �� - , . M By........ �* Title ----------------- ----- Ilf of er than owner] F R DEP RTMENT USE ONLY APPLICATION ACCEPTED BY........ .. .... Q ---- .........DATE ....7.. - ?�/ -.-7-....-. DIVISION OF LAND NUMBER. ----- DATE--- --------------------- ---- ---------------- -- --- ---- ADDITIONAL COMMENTS....._. . ��-- --.r2�G.t.----L2�-�.�'. .............. ..... . --- ----------- • -------------- --------- --- -------------- --- ------ --------- g 17 / �p�. ... 1 h -.- -------- -5 ...s_2_14-- ----------------------- ------- Final Inspection by .............. Date. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fay 21677 REV, 7/76 3M