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FOR OFFICE USE: FOR OFFICE USE: 6aAPPLICATION FOR SANITATION PERMIT - - 79- 3.yb (Complete in Triplicate) Permit o. . _ . ' -_..-__.__..__..__.._._..........__.._-_. This Permit Expires 1 Year From Date Issued Date Issuedi... Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Phis application is made in compliance with County Ordi nce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO . -l___ e �_.._��_ ,. - . ._______.CENSUS TRACT.--......._-/- ....__-.__.. Owner's Name-. � -------- ----------------- ----------------------- 6'Address...... - - S - �Lc /- �- . . cityzip ------------ Contractor's - - Contractor's Name.-.------ ...License #__32 .Z _Phone---------------------------- `Installation will serve: Residence Apartment House El Commercia Trailer Court ❑ Motel ❑ Other_- Number of living units:----t-------Number of bedrooms-.1Garbage Grinder----_......Lot Size.--_-- `Water Supply: Public System and name--------------------------- -------------------- - ---------------------------------------- -------------------------------Private Character of soil to a depth of 3 feet: Sand E] Silt F] Clay E] Peat E] Sandy Loam ❑ Clay Loam El Hardpan V Adobe ❑ Fill Material_ ---------If yes, type--_ --------_._..._..._... V (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 seep ge pit permitted ifpublic sewer is available within 200 feet,) E TREATMENT [ ] SEPTIC TANK [ _ 1� C It.PACKAGr'1 Size7 -�-1 - -------- -- Liquid Depth.--.. ------------------ aQ Capocity__Za E ----Type-JZ aterial_-._ -- -----No. Compartments---�--------------------- � Distance to nearest: Well__ _._ L�. _.___-..----Foundation._..-----FF---..Prop. Line_..---._ `LEACHING LINE ['] No. of Lines.----------3-______Length of each line.------- Length .__ A 1`_-_._..----- 'D' Box---- -----Type Filter Material___r_S ----- Depth Filter Material..-._._.I.V-"------------------------------ _--------- ` Distance to nearest: Well____ z _-Foundation_----`QZ,_'_'---------Property Line.._-r, 4-,------ ........ . SEEPAGE PIT Depth..2c Diameter....-_3_ .__Number-..-._._--- 13------------ Rock Filled Yes No ❑ - ocze..:•. v� Water Table Depth--------------- - -------- ------- --- Rock SiJ�--- -�---/------------ Distance to nearest: Well-- Foundation_ _Prop. Line----_.-�' ..- REPAIR/ADDITION (Prev. Sanitation Permit#-_.-_..__................._--------_.._..--.Date.._......_-...__.------._-.__.--.---.-_.) LSeptic Tank (Specify Requirements)--------------- -------------------------------------------------------- -_ - - -- -------------------- ---- --- Disposal Field (Specify Requirements)---------------- ------------------------------- -------------------------------------------------------- ----------------------------------------------------------------------------------------------- -------- - -------- - _ - --.. --- --------- -------------------------------------------- I- ___- (Draw existing and required addition on reverse side) 1 hereby certify that 1 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 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 4 (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - ------------4---- -- ---- ---- ---- —DATE - DIVISION OF LAND NUMBER -- - ---- ------------ -- - ---y-------------------------------------------...-------- ----- DATE.---- - ---------- ADDITIONAL COMMENTS---.._ - _ --------------------- ----------------- ------------ ---------------------------- I - --------- I -------------- - Ir --------------- ------------ - --------- ---- ---- --------- Final Inspection by:----- ---------------..__ --. _ jj`--. - - --------------------- ----- ----- ---------Date - --- / - - ---- --- - - V Ex ♦S t3 zd SAN JOAQUIN LOCAL HEALTH DISTRICT F "N"677 REV. 7r7e 3M