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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 --------- --------------------- ------- ------- ----------- (Complete in Triplicate) Permit No. - - ,x. Date Issued------- This Permit Expires 1 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. 4 This application is made in compliance with County Ordinance No;549 and existing Rules and Regulations: �j .. N.JOB ADDRESS/LOCATIO2 --- - -- ---1--- - a ,� CENSUS TRACT ----- - - ---Owner's Name... , ----------Phone--- - Address-------------- - y--- --- ------ ------ -- - --city --------------------- p----------- -- -- ----------- Contractor's Name -----License #-.J2- ----a4---Phone-------------------- Installation will serve: ' Residence ❑ . Apartment House ❑ Commercial ❑ Trailer Court ❑ i a Motel ❑ Other--- ----- . _ �R Number of living.units ---------Number of bedrooms.__r _.Garbage Grinder-.-.: ------- Size-.----------1--- Water Supply: Public System and nam? ,' - =- -- '---------- ------------- _------------ -------------------------Private Er", Character of soil-to a depth of 3 feet: Sand ❑ `Silt❑ Clay ❑ Peat E] Sandy Loam E] Clay Loam Er - _ Hardpan.❑ y Adobe E] 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: ;(Nos-septic tank or seepage pit permitted if'public.sewer is available within 200 feet,) PACKAGE TREATMENT [ ] 'SEPTIC TANK [ l Size---------------------------------'-----.- - - L'iquid'Depth= —____:77777: r- !. � Capacity=------ ---- -- ---Type---------------- Material No. Compartments W ..Distance to nearest:.Well_s_............_.: .,'= ----- ----4 Foundation--------------.!----.J.—Pro'p. Line`----------------------'-_ � LEACHING LINE: [:] No. of Lines-..__-_r. ----- Length of each line---------------___________,__:Total Length _____ -.--_;----- l ,s D' Box --------:--Type F1.lter Material_ .- Depth Filter Material------------------------- - - -------------- ._ s :. Distance to nearest: Well--------------- -----Foundation- --------- - ----V --Property Line------------- -`-- :=--"--- --- SEEPAGE'PIT [ ] Depth-----------------Diameter--------------------- Number-- __= ==__c-:-- - :-.--- Rock Filled Yes❑ No E] ( Water Table Depth--------------- ----- --------------------------------------Rock Size--------------------------------------- "Distance to nearest: Well-------- ---- ----------------------------.Foundation--------- ------------ .Prop. Line-----------------------'---. DITION anitation Permit#-- --: -94-74_ -- _ _---_ ----__ _ -Date.__ --_ -r REPAIR/AD (Prev.. --_- ----'-�-'� ��------------) . Septic Tank'(Specify:Req uirements)---------------------------------------------- --------------------------- -------------------------- --------------=----------------_-------- ----------- 1 Disposal Feld (Specify Requii•ements):-.- .G✓-._ ___ " ---___-_-L4?�-RQ - ----- ---- ------------------------------------------ --------------- = } --- - - --- ------ (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 P signature certifies the following: '1. i 1 "I certify that in the performanceof 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.". + 4 ' Signed _ Ownar _ + -. BY ----------- ------------------------------------ -Title ;v -------------- ------------- J I f -----------(If other than owner] y t FOR.DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-: -------------------- ------ - ----- ------DATE.DATE.i�----- --- ----------------- DIVISION ---- ------DIVISION OF LAND NUMBER------- ---------------------------- ----- ---------------------------------------------- DATE ------- -- - ADDITIONAL COMMENTS -------------------------------------- --------------------- --------- ----------------- - = - ------- ------------------- -------------------------------- 7 ------ ----- ----------------- b ------------ ------------'---- -- --- --------------------------------------- --- ----------------------------------------------------- --------------------- Final Inspection by: = `- - - -- "` -'-------`-_ `= = = ------ --- --- Date ' - -� ' EH 13 24 SAN JOAQUIN LOCAL HEALTF$'DISTRICT Fas 21677 REV. 7 76 3M