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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7�` S ------------- -------------------------------------- (Complete in Triplicate) Permit No. -------------------- -------------------- ------------- This Permit Expires 1 Year From Date Issued Date 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/LOCATION. I _O_ :36 --------------- f CENSUS TRACT. Owner's Name--4:: ---- -- ------------------------- ---------- ---- ---- ----- -------- -Phone---- ------------------------------ Address_ -G- - � - City -- ---- --G- - zip M - �., e 3 - Contractor's Name s - ' `"`_ �- - �---------------------License #��Z2�� Phone_------------ t Installation will.:serve: Residence [Apartment House.❑ Commercial ❑' Tr'ailer Court [_1 Other- Motel ❑ --•-------------- . ..}w __-_..,-__-- Number, of living units:--------- -------Number,of.bedrooms-____'.___Garbage Grinder-------_---Lot>Size---.____-_Z-------- ----------------------------------- - Water Supply: Public System and name--------------------- -- ---- ' - : _. ----------------------' Private Character of soil. to a depth of 3 feet: Sand E] Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ i Hardpan Adobe;❑ Fill Material__ ---------If yes, type-'-,---___ __________________ r - d [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, y PACKAGE TREATMENT [ ] SEPTIC TANK [ Size �----�-1`�''-------X--"�� ------------- Liquid Depth ------ -41----�---� Caacit p Y-(6TYpeC c� a Material __ '' ----�------------ ------Fou��nd on____No. Compartments----- _ .� ----------- f Distance to nearest: Well----_------Jr__b r 1 V__t-_.------Pro Line._._____. _ ---------- LE4CHING LINE,LINE. ['� No. of Lines_-____•__________________Length o, each line______- --------_------Total Length._� D' Box._._'.___'.._Type Filter Material---- J�------Depth Filter Material_._ �� " ] r --------=- Distance to nearest: Well- -4�--�'----- =- - Property - A� 1 _ Foundation__"--,f_�J_______________.Pro er Line-------- ---------�rF__-,--___--- SEEPAGE PIT [ ] Depth__ '__ _Diameter_: -- .__ ---Number----____�_____________ ____ Rock Filled Yes No ] Water Table Depth----------------- ------ --------1---t-- ---=-:---Rock Size----� /-`Z Y- 3 r f , Distance to nearest: Well-- _-___E=_p_p.__________�___ Foundation-______l__�_____.__-__ Prop. Line------ __r----------- ___. I -- - —r" _ ) REPAIR/ADDITION [Prey. Sanitation Permit#__ � ------------ _________________ ____________Date_--___________________ __-______. __------- , Septic Tank (Specify Requ_irementsf----_---_----------- _ --------------------- --------- - v Disposal Field (Specify Requirements) A.' = --------------- ------- -------- --------------- _ �_ t = ------------- -------- ---- ---------------------------------ff-ff------------------------------------------------------ ------------- - ----------------- x`21 —I ------------------------------ =---------------- ------`,- ----------------- - ---------------------- =--- - -- i - --� (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will -be dome 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: t � "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." t Signed------------- - ---- - Owner BY -------------------- ---- Title (If other than owner) ' FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY DATE ---_.. DIVISION OF LAND NUMBER- -----------------•• ------------ DATE-------------------- --,--- ADDITIONAL COMMENTS-- ---- --------------------------------------------------------------- - F , _________________ __________ ___ -------_-------------------------------------------------------------_-----_________-----------_-------------------- -------------------------------------------- - _- ____.__•___•------------------------------------------------------------ ---_ - --__ - Final Inspection by: = ------------Date-- EH 13 24 SAN JOAQUIN LOC HEALTH DISTRICT ess 21677 Rev. 7/76 3M