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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT —L E, (Complete in Triplicate) Permit No-- ___.�--.-.5.--- Date Issued ------------------------------------------- ------------ 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. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC T ) - U - _CENSUS TRACT Owner's Name -- - -- --- Phone---- ---- -- ----- -------- ----- Address. pj ----------------- -- - -- --- - ty- ---- ' AGInsContractor's Name-- -- `----------------------- License # 21S---- -----Phone.0-Z ------------------ Installation=w tallation=will serve: ResidenceX ApartmentHouse.0 Commercial-❑ "•Trailer Cour .. Motel ❑ Other= ---- --- ----------------------------- J/ -- --- [_------=---- g 4 g Number of living units:,-- :Number of:bedrooms-- Garba a Grinder.__.-v--- Lot.Size---.�-.�_ Writer Supply: PLblic System and-name ----- :-_-- - -----.---- ----.- _ _ -------------------------------- -------------------- -- ----- - --- - - Private L. I Character of soil to a depth of feet Sand ❑ Silt ❑ _CIO Peat❑ Sandy Loam ❑ Clay 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-perni fited if'public sewer is available within 2D0 feet,) PACKAGE TREATMENT [ j" F SEPTIC TANK t•' ----#"_F-- "__-_- __ "` " `q r [�� Size-------------- --- ; . -= - -----Li uidYDepth - - ---------------- t O Capacity...=----------------=TYpq�;=--------------- ---.Material-----------= `.. ` = No. Compartments-. ' i r Distance:#o nearest: Well-:-"f- ------- ----------Foundation------ ------------------Prop. Line_;.-----=--------------- 00 LEACHING LINE [J, No..of Lines__1__________________________ Length of each.line- ------------------------------Total Length--------- ----.- - '_-- D' Box-- -.-- { Type Filter Material-- - -------------Depth Filer Material___F___.__------------- --------- ------------------------- _1 - Distance to nearest: Well-=---- ---------------------Foundation------------------------------Property Line-. --------------------_---------- SEEPAGE PlT f ) Depth_.__:--.___-E--Diameter-------------------- Number---------_ ------:----_-------__ Rock Filled . Yes ❑ No - Or- A. -r..- ..t - Water Table Depth-------------------------- ----------------- --------'-- Rock Size:-------------------=------------ ----- ----- e .. ...pint' ; • �`___` t � G ante to nearest: Well ---------------------- -Foundationu`W.'."-1 -Prop. Line r. REPAIR/ADDITION {Prey. Sanitation Permit#-------------------------------------`---------- --_.Date------------------- ------------:----_---___-) Septic Tank (Specify Requirements) -----------t = - ------ c' - Dispo I Field (Specify Requirements). ✓ -�. t `�� --------- ---------------- ------------------------- ------ -- ---------------------------------------------------------------------"--------- ------------- -------- ---- ----- ------------- (Draw -(Draw existing and required 'addition on reverse side) e� d 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'i r licensed agents signature certifies the Following: ..I certify that in'the performance,of ithe work jor which this permit is issued, .l,shall not employ any person in'sucFi manner as to beco- s bie to W man's .Compensation laws of California." - Signed-- --Owner C__ //�� By-'.- --------------------- _----t-_ -------- :(� a itle------C ' ---- -- ' (If other than FOR DEPARTMENT USE ONLY` APPLICATION ACCEPTED BY -- -- ---------------------------------------------`----------------DATE.----- .--------- ---- DIVISION OF LAND NUMBER---------- - -- ---------------_ DAT)--- ---------------------- ----- ----- ADDITIONAL COMMENTS------------------------------------------------------------------------------------- -- ----- -------- ----- ----------- -- --------T---------- ----------------------------------- ----------- ------------------------ ---- - -------------------------------------- -------------=-------------------... -------- - -- ----- ---- ----=-------- ------- -------- ---------------- --------- ----=--------- - ------------ ��' -------------- - - -- - ------. ---------- to Final Inspection 6Y:-'+ = = i �� f / ------------------- - Date - l _��c _= �-. EH 13 24 • SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M