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FOR OFFICE USE: FOR OFFICE USE: ' "APPLICATION FOR SANITATION PERMIT 11 ? �J/� (Complete in Triplicate) Permit No.-7�_'-7s__�_- -- 6_-`-- ---------- '----------------------------------.------------ This Permit Expires 1 Year from Date Issued Date lssued__F-7!5`-;�7 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. chis application is made in c mp 'once wit unty Ordinance No. 549 and existing Rules and Regulations: JOB ;DD - G� -------- - ---------- -- CENSUS TRACT JOB ;DD Owner' Name �� _ ---Phone ------ Address - 1 'A" - 2 .Cit Com ; '` ` # - Zi �f Contractor's Name 1 �'� "`" -' �- 4-�----- - License #_ ----Z- -----------Phone--------------------------- -Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 01 Motel ❑ Other..__`=1' __------ .J- -_ _1 Number of living units:__ gSize \V� __ Number of bedrooms.._2"_..Garba e Grinder.______...__Lot ____. Water Supply: Public System and name ----------------- ----------------------- ---------_------- -- --------------------------------------------------Private �- Character of soil to a depth of 3 feet: Sand ❑ Silt E] Clay ❑. Peat ❑ Sandy Loam ❑ Clay Loam ❑ 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 INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKSize - - _ _ _ - _.. - -- Liquid Depth .-... . . . _ [ ] -. ._. ... Capacity _ . . -Type..... Material No. Compartments - --- -- Distance to nearest: Well _ _ __ _ _................ Foundation _____ ._-.-_ __ ___ Prop. Line__.._-_ LEACHING LINE [ ] No. of Lines ---- Length of each line _ _ __.. .__ ._.__ _-_Total Length .._._ 'D' Box __ Type Filter Material __ -----Dep,h Filter Material-----------____-_._.__ Distance to nearest: Well.__ _ _.Foundation ___ ____________________Property Line _ ._____________._ SEEPAGE PIT [ ] Depth . Diameter__ _ _Number _______---____ __ __-- ------- Rock Filled Yes ❑ No❑ Water Table Depth ------ --- -------------------.Rock Size--- ----- - -- --------------------- Distance to nearest: Well -------_ ----------------------Foundation__---------- _ _ .. . .Prop. Line----- ..____._ REPAIR/ADDITION (Prev. Sanitation Permit#_-.-_____________________________________________Date-.-.--_-.-__.-..__.__.__ _ __ ---------_) -Septic Tank (Specify Requirements)------ - ----------- R----------------------------------- - - �f f Disposal Field (Specify Requirements)-----6 ��-�S-rJ---� C�-x ----R E-- -----=r'-t_`---------- -- --- e,2 ��-.-- -----9/=-------------------- " ---------- ---- ---- ------------- (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 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 r s - -Owner B .-- e ..t_t,a Title- Y - 1.. 1 ` (If other than owner) R DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY--------- - --- -------------------- ------- ------------ ------DATE - DIVISIONOF LAND NUMBER------------ -------------------------- ----------------------------------------------------------- ----DATE ---------- ------------------- ---------- - ADDITIONALCOMMENTS --------- ----- ------------------------------------------------------------------------------------------- -- ----------------------------------------------- - - ---------------- - .. --- - - -------------------------------------------------------------------------------- ------------ --------------------------------------- ........ --------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- -- ------ rOAQUIN ------------ - - -------------- ------ -- --------- -- ---- ---- Final Inspection b - ---�- Date1 P Y:------------------- ,} EH 13 24 SAN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M