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FOR OFFICE USE: FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT Permit No. M7 �3 --------------------------------------------- -------- {Complete in Triplicate) ---------------------------------------------- � ----' .Date Issued.------"--'_-.- This Permit Expires t 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: �}-- __.. ----------- JOBl._�.- - -----------------'----------.CENSUS TRACT.-- ------------------_- --- ADDRESS/LOCATICI _ tc 1_ Owner's Name-------------0--------- ' --.------------------------ ------------------- -- -------------------Phone----------------- � ----------- �..r --J--- -- - ipAddress---- ---------------'----..ZA-0 ------------------ ----- -------------------------------- -" PhoneLicense # S Contractor'5-Name Installation1will serve: Residence4W Apartment House ❑ Commercial ❑ Trailer Court ❑ r Motel ❑ Other---=''y'------ ----=- Number of living its:-.--- s _y �:Garbdge Grinder__- _.Lot Size_.____._ .__'___ ---------------------------- u m _ Water Su tl Public System and name--- --------------------- -fit "�s '` -, - ------------------- Private ❑ i Supply: y : ;' = Character of soil to epth of 3 feet: : Sand ❑ Silt❑ Clay ❑ Peat ❑ Sancly_L am ❑ Clay Loam E ardpan E] i 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:�seepaigbipit permitted if public sewer is available within 200 feet,) I // . PACKAGE TREATMENT [ ]��SEPTIC TANK [ ]r +., fSize--- yy !�� Liquid Depth.___4° _________{___ l Size ' /_off �__ -- --- X --- Capacity_/. L TYpe_ f= Material--- - --------------No•"Comp artmenfis --------------- �b, S. t ��, �q to nearest:.Well------�_--__------ -----------Fou'nd�n.._-..,'------- -'---'--=Prop. Line----------------------------- Distance LEACHING !LINE [ ] No, of Lines___ -_ ----___.__.Length of eachline.-07 -----------------Total, Leng h.__._ �-- _-_--------.--- y. Yp 'D' Box.. _-___.._T e..Filter,r,Material-_If7-�� e th Filter Material____ __ p ��" = Distance to nearest: Well__1'________________ ___ Foundation ,_:___--------------Property Linef_.._-- ------- -- ----- SEEPAGE PIT [ ] Depth----------------Dia meter_____----------: --Number------------------------------_- Rock Filled Yes ❑ No❑ WaterTable Depth-----------------------------------------------------------Rock Sije_.--- ---------------------- ------------ .1A Distance to nearest: Well----------------------=--------------------Foundation- ----- -----.Prop. Line--------------------.-------- REPAIR/ADDITION (Prev, Sanitation Permit#---------------------------------------------------Date----------------_-'- : ;'--_-------------------V. Septic Tank° `T� --------------------- '(Specify Requirements}- _---- �---- ----' -- ----------------"- ---. --------------------' - ------------------------------:--- ---'- Disposal.Fi p € eld (Specify Requirements)-------- -------- ---- -------------------------- -------------------------------- ' ----------------- ----- ---------------------- ------ ----------------------------------------------------- --- ---------- ------ ---- ---- -- ----------- ----- ---- " --- ---------------- --------- ------ --------------------------------------------- --------------------. . -- --------------------Eon reverse----------------------------------------- ; 7 f {{Draw existing and required addition side) y� I hereby certify that I 'ha'Ve prepared this application and that the work will be-done in accords ce�with'"San Joaquin County Ordinances; State Laws,- and Rules and Regulations of tFie San�JQaquin_Loeal.Hea th_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 becomelsubject to Workman's Compensation laws .of California." --- Owner Signe' d------ ---�- �.. - - - -- = ---'----'- ---F---•'-- ----------- ------Title--------- I # (if other than owner) { i R' DEPART ENT USE ONLY i APPLICATION ACCEPTED BY ----- . -' DATE a DIVISION OF_LAND.NUMBER---------------- --------------- `--t- _ � �.. ... DATE ' ADDITIONALCOMMENTS------------------ -- ---------------------------------------------•----------- ------------- !------=--------------------------- ------------------ -------------- - -------------------- ----------------------------------------------------------------- ---------------------- ---------------------------------- ----- - -- ----- - ------------ ---------------------------------------- --- -- - Final Inspection by rte -- ----- ---- Date a i 24 SA JOAQUIN LOCAL HEALTH DISTRICT F&S 21577 REV. 7/76 3M �' - -