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FOR OFFICE USE: f .:..,PLICATION FOR SANITATION PERMIT _ FOR OFFICE USE, __`-- (Complete in Triplicate) Permit No.-Z?7d-" Date Issued1d_� __�� j This Permit Expires 1 Year From Date Issued A pplication is hereby made to the San Joaquin Local Health District fora per it to can st This application is made in compliance with County Ordinance No. 549 and existing Rulers and Regulationuct and install s: work herein described. JOB ADD RESS/LOCATION_..__!_3�1D"--_�! �j . '-------.CENSUS TRACT Owner's Name.-.------ ` y -= -----------Phone Address----- ------ --- �Q9 _ ----- Contractor's Name------ ----------------------Zip s --------License �--�-Phone-------------- Installation will serve: Resider ❑ Apartment douse. Commercial ❑ Trailer Court ❑ ! Motel ❑ Other_-_:. i Number of living units:_ _ ---------Number of bedroom s_i:__zs _:Gcrrbage-Grinder------------Lot Size __" ;. , Water Supply: Public System and name------------------ `--------------------------------J--------=----- , Private E] ------ ®� C aracter of soil to a depth of 8 feet: Sand Silt❑ Clay ❑'..�. Peat Sandy Loam ❑ Clay Loam ❑ Hardpan [i� Adobe❑ Fill Material------------IfY es tYPe ---- (Plot pian, 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,) i PACKAGE tREATMENT [ I SEPTIC TANK [ ] Size__________________________ ----------=---------------------Liquid Depth--------------------------- 'Capacity Type p Material No. Compartments---------- -------------------------_; LEACHING s Distance to nearest: WeIL-------------------------------------" n_.__--- -" ---_ - - -----=-- --:_Prop. Line--------------------------- QV SINE__ [ ) No. of Lines_______--____---------------Len..th_of each line." Foundatio -' - - g ___ ___ .Total Length----------------------------------------- .'D' __.. __'D' Boz-- TYpe Filter Material d - --,_Depth Filter Material = = Distance;to nearest: Well-----------------------"""--Foundation----------------------------.Property 'Line----------.--_----------- SEEPAGE PIT [ I Depth . __.; _-----Diameter-- - Number--- -Mrv'----"_-_-- --- "" Rock'Filled G Yes ❑ No ❑ Water .Table Depth-.: ---------------------------------------- ---.Rock Size. Distance-to nearest: Well--------------------- --=----------=------Foundation----------------------------.Pro Line------_ ----------- ._ REPAIR%ADDITION (Prev. Sanitation Permit#-------------------------------------- p � � ' -----.:Date--------------------- Ift Septic Tankl{Specify Regyirerrents)_.__.------------------------------- --------------------------- Disposal fe (Specify Re uiremen 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 1 signature certifies the following: s - "I certify thaf in the-performance of the work for which this permit is issued, 1 shall not employ any person in uch manner as to become subject to .Workman's C ensation laws California." Signed--------'-------------------------------- ------------ - Owne,r BY----------------------------------------------- Title. (If other t pn'°owner) ------------------- - FOR DE RTMENT USE ONLY APPLICATION ACCEPTED BY > ..... --= DATE._./_4' DIVISION OF LAND NUMBER. -----------------------------------------------------------DATE------------------- --- ADDITIONAL COMMENTS----•---- ----- ------ ------------ - -------------- ------ ------------------------------ ------------- ------------- -- -------------------------- --------------------------------------------------------------------- Fina! Inspection by---- ---------------- -'""---- -- � ----_-_--Date_--f�-� "� ""-- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M