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��OR OFFICE USE: FOR OFFICE USE. ` APPLICATION FOR SANITATION PERMIT ------------=------ :-:: . . (Complete in Triplicate) Permit No. .�: - ---------------------• --.._............................ This Permit Expires 1 Year From Date Issued Date lssued_/P_: 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 Cou ty Ordinance.No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION' .020?o4p.. ..........CENSUS TRACT......rn.-------.. ---. Owner's Name.- -.-.- .. Phone------_............. . _ ... .....- 77 Addres s.s,.1.r•A.d Cit Zi _ --- -- ---- ... -- Y P :... y� ..-- Name......._._/arGQ:.�" ... ��"--. ...................................License #_ .�«---s3.�...Phone-_Irr `^----------- Contractor's . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- --- - -------------------------- -------- Number of living units..... ---. --Number of bedrooms.-CAGarbo rGrinder-..-------. Lot Size---.... Water Supply: Public System and name....... ......... .. t ... 4.JZ,4�oaz -...._..--•...-.--....._ ---- --------------------- ❑ i Character of soil to a depth of 3 feet; Sand ❑ Silt❑ Cloy ❑ Peat ❑ Sandy Loam ❑ Cloy Loam ❑ Hardpan ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) . G_ PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size -,... -_. .-..-.-Liquid Depth ...................�� Capacity----------------- ---TYPe-----•-----------------Material--------------- ..........No. Compartments... ...... .................. ) Distance to nearest: Well-------------------------------------------Foundation---_---. .... ...Prop. Line------.-.--..-.---..-.-.--- LEACHING LINE_' No. of Lines ---------. _ .-..Length of each line.......------------------- --Total Length __ _______________ 'D' Box............Type Filter Material....-..----... -- Depth Filter Material------- ----------- ----- 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 (Prev. Sanitation Permit#-------------------------- -------- --- - --_._Dote--------------------------- -- --------- ] Septic Tank [Specify Requirementsl....-- ----- ....-• ---- --------- ----- - ---------------. -- ----.....------ -- -- ....-...............-... --- [ . . c� 1 Disposal Field (Specify Requirements)- - - -.-. .-. .... ------------- ----�--- - -� ------------------- .................... -----------.------ ......;................. •--• --•- ------------------------------------ ----------------' . . ....... . ....... .... . ...... -------------------- ............... f [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 beco e s b' t to kma ComP en0atio-n laws of California." t Signed . ........ ---- ... Owner BY-------- ---------- -------------------------- -- ._ . 6 Title..... ... -- ----;...-- . (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-, ..... . .SIA—.. ... . --------------------------------- ----- ..--...DATE {b��~ ----------- ; DIVISION OF LAND NUMBER. ..................................... --------- DATE---- ----- ------ ---- ---------------- ADDITIONAL COMMENTS-.......... ................ ----- --- --.....--- ..... . ........ ..... - ------- ------------- { i l --------------------- -- -------• ------ -------------- --------- --- ------ -- ------- ------- --------- Final Inspection by:-----� 5----------------------------------•- •------------------ --------------------------------Date.......tDt --\�_ \7 ......'°'..... EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F65 21677 REV. 7/76 3N