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I FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT LDote OR OFFICE USE: ] ... _._ (Complete in Triplicate) t No... -7g n:J . - --- -- - This Permit Expires 1 Year From Date Issued Issued:- ,Q.. 6-JX/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This appplicatii9 n_its m�/,��{� in li ith County Ordinance No. 549 and existing Rules and Regulations: JO� ESSj[pCATION _ trG Zx a✓ f•,_ --... ....". . ..CENSUS TRACT....... .-- Owner's Name _ .. _ �:,__ff Y\ F ` -.... .. . Address..__ ._ ' 21 i Phone __ ......City.. -ems . ... Zip- (B� +z � / ( 2 Contractor's Name. .. .... ...e .. 'R _ca.-�• Eft #. JFZz :. .. - .".Phone .._ . .. Installation will serve: Residence [I� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other. Number of living units: ..... . ..... .Number of bedrooms_ 3--.Garbage Grinder._. .._.Lot Size ..... .. If 024 t_� Water Supply: Public System and name........ ...... - __... - - -�/ _..Private []� Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam Lf 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 INS : (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [Al' Size �l f X S J / �r .. ..-----.Liquid Depth Capacity .Lo!:QQ._.._Type J��Material *,C!".'.'+ C- No. Compartments Distance to nearest: Well Foundation.......( O Prop. Line LEACHING LINE le No. of Lines .._ ... �_----. Length of each line- __ . ._f`".�. .."...Total Length 1-0.6 'D' Box_._A ..Type Filter Material_ s_.R .-__ Depth Filter Material .._ -____ . _-L!�.- y' _ _ Distance to nearest: Well. O t 1 r - r } 3 b ..... .Foundation .__�, � -...-_ _Property Line .. ..�� __ SEEPAGE PIT ] Depth---Z-r.....Diameter._ . _.. Number._ - Rack Filled Yes 2r`�No❑ Water Table Depth................ �'!."�.............---------. Rock Size.-- -? J Distance to nearest: Well.. _". / -�_ ------..-.-__......Foundation... _ ------ "".ProP Line.... 7... .......... REPAIR/ADDITION (Prev. Sanitation Permit#....... .... ....,.:,1 -------._....--.----.._."....Date_ _-- ----- _. Septic lank (Specify Requirements) ----------------- +sposa Field (Specify Requirements)........ . .. . ---- -- ------ raw 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..T 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 become subject to Workman's Compensation laws of California." Signed ... . __Owner By- -- (If other than owner) FOR PART ENT USE ONLY APPLICATION ACCEPTED BY_... _. .. _".. .... DATE DIVISION OF LAND NUMBER . _ .._. . ADDITIONAL COMMENTS........ .. """ " -' "" " -----..----__......DATE ....._... _.._ .. _...""_--------------- .. ........ .............. -- - - --- ....._.......... . ............ - - .. Final Inspection by . . "- - - .. ...................... rfjti EH 13 24 - --.-.Date •'I - - — -- - SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M