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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------'------------=---------' ................. 1 . Complete in Triplicate} Permit No, 5 �.. y 'P Date Issued. / 7 G Permit Expires 1 Year From Date Issued !yL/'l This , Application is hereby made Ito 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 kules and Regulations: va JOB ADDRESS/LOCATIO �o � ........_CENSUS TRACT .... 5``�� _ --.. 0 E ' Owner's Name. / vCr.- 1 .�1 a, c. -- "--- .. -----Phone__ - Address G.- - ! =+� '' ---- ........ <"".._City-- Zi J`?�0 .. _ f _, . I?" Contractor's Name �"` ------ -- License #._32 .. Phona- -...: Installation will serve: Residence Apartment House ❑ .Commercial ❑ Trailer Court ❑ J Number of living units;.......!_._- edroo❑ms,-.Or!..._.Garbage Grinder Size_-.- -^r"--fit.. Mo ----------- Numb'er of b' mow» Ch ---------------- - -------------- Water -- (te W aractepof sop tof Public destem tli of 3dfeetme�San------------ -------�- --'----------------------------------------I-- ----------------- --- ----..Private p d Silt❑ Clay ❑ Peat ❑ Sandy Loam �lay'Loom ❑ Hardpan ❑ Adobe,❑ Fill Material_- ---------1f yes, type..-- ----------------- (Plot plan, showing size of lot, location of sysfiem 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,)' PACKAGE TREATMENT [ .] SEPTIC TANK [ ] Size ---- ------------------------ --------------- --Liquid Depth------------- -------- ----- Capacity - Type Material, --------- .----N'o. Cgmpartmbnts...:-1-------- --------- ----- Distance to nearest: Well -- -------------- ----- - Foundation.. ------- -- .Prop. Line..:---. -- LEACHING LINE j ] No? of Lines---------------- =--- Length-of each .line------- ------_.-- .....Total Length--------------........... '----- . . 'D' Box -------..Type Fjlter Material- -----------'- Depth Filter Material ... ..........- --- ------------------- ----- -------- _Foundation_-._. ---Propert Distance to nearest: Wel!--------------------------- - - ------- Y ----- - ---------- ------ - Line.. SEEPAGE PT De th------ --------Diamstet-----,---. ..Number----------------------------- -- --- - - Rock- Filled I e d Yes No-E] Water Table Depth.-- ------------- -� ------ --- --------------------•------.Rock Size....----- _ ----- Distance to nearest: Well------------------- __-_--'_.Foundation----------------- ---...Prop. Line- ------ ----_. REPAIR/ADDITION (Prev. Sanitation Permit# ------- ----------- -----.Date------------------- ------ -----} Disposal Field (Spe Re uireme sJ_ ----.--- . ------- -----�------------------- - - ' ' --- -------- ------------- ------ --------- Dispc Tank (Specify Requirements) --- _. 1�.� C=am ..Few -- � � ----------- ,� - ------------ 1- � .- - .� -- ----- ------- ---------- --------------- ----- ------------ --------- ----------------------------------------------------------------------------------- ------- •---- ' (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 signature certifies the following: "I certify that in the perfbrmance of the work for which this permit is issued, I shall riot employ'any person in such manner, as to become subject to Workman's- Com nation laws lifornia." Signed--------= ........ -=-- --- ------- - -------- ----------- - -- - - - ---------- By------------ ..By------------ -- _Title--.J.`.. .. --- ----------- (If other'than owner) ' a FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY__:.- . .' ------------ -- ---------------- DATE &DIVISION OF LAND NUMBER_ .. . � . ------ - ' -- - ---------------------------- ---..DATE.........-------------=----------- ...---- ADDITION AL COMIVENTS.....—..-,..... - .........�_ _ ................................................ , ---•--------- --.- ---- -- ------ ---------- - ----- ---------- •-------- `----- 1 , --- ----------- -------- ry - -- Final Inspection b -- ---- - - ------l--------'---Date:•. ... ( ' 6 E".13 24 { SAN JOAOUIN LOCAL HEALTH DISTRICT, F&S 21677 REV, 7/76 3M