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FOR OFFICE USE: FOR OFFICE USE: rAPPLICATION FOR SANITATION PERMIT Permit No.. (Complete in Triplicate) Perm ------�--- Date Issued_ j.---------.-----------.------- ------ ---._.....___". This Permit Expires 1 Year From Date Issued Application is hereby made to 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�x_ee� inancce No. 549 and existing Rules and Regulations: `JOB ADDRESS/LOCAT/,I/O/�1.--_ .. -(N ----- x - -------------------CENSUS TRACT_------------------------ Owner's Name---------�------�.--- -------- - -- -- - ------------------------ ----Phone--------------------------------- rAddress -- � /.40� City Z p- ---- - --------._. Contractor's Name-------- - - - '- ------ - ----------- f�-"'.`n,°--�Fd---.'_"'License #---- - - ------- phone"-----------------..-.-.-...- .Installation will serve: Residence ❑ Apartment House❑ Commercials] Trailer Court ❑ �/ Motel ❑ Other___.Cr.-sL, Number of living units:_./_._._.."_ Number of bedrooms__..3__Garboge Grindef-___._ .__Lot Size--- / - a--__._"_ - .Water Supply: Public System and name----- ----------------------------------------------- ---------------------------------------------------/-----------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay❑ Peat❑ Sandy Loam ❑ Clay Loam 21_� r Hardpan ❑ Adobe❑ Fill Material._----------If yes, type ------------------.----___. �\ r (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 a/vailable within 200 feet,] `PACKAGE TREATMENT [ ] SEPTIC TANK [� Size_ .�.f -------------.-Liquid Depth---- ---F--- Capacity. _...._Type. . __. .. .Material,4_ -P-->✓.-_._-No. Compartments---2- 11 / Distance to nearest: Well ------------------Foundation..... -----.Prop. Line----- - '- LEACHING LINE No. of Lines------_7-'-------------- Length of each line.._....�p--- ._______Total Length._._ _L2_____---._._ _ 'D' Box---- -----Type Filter Material-----Se-----Depth Filter Material.........,1-9.-----___...___".__................ ..... ! .. Distance to nearest: Well__ S.__.. ._ Di._.___._.__Foundation._.... ---------Property Line- ----------- S6 T � Depth-----._�O_"_@iematec 7__�'L- Number___:________.-__.....__ Rock Filled Yes j�No;❑ Water Table Depth-------------- �.- ----------------------------.Rock Size---..�----....- 1 ----------- Distance to nearest: Well------- ....... .Foundation-.._/d.�. --------Prop. Line.__.. REPAIR/ADDITION (Prev. Sanitation Permit#.______.____.._...,___- ......__............Date------------------...........__________._._) Septic Tank (Specify Requirements]--------------- I-------------------------------------..------------ --------------- ------------------- -----------------=-- Disposal Field (Specify Requirements)-----------. -------.... ---------- ------...----------------------------------------------------- "------`--"---------- (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 _. Owner By, _...- -- -Title-- -------- ---- (If other than owner) FORftARTMENT USE ONLY APPLICATION ACCEPTED BY------ -t-- - - DATE.--- 2� - ----- ------------------ DIVISION OF LAND NUMBER--- - ---------------------- -- - - DATE--------_... . -----_----------- ADDITIONALCOMMENTS-------------------- __.- - ------ --- -------- ------------ ------------------------------------- --------------------------- ----------------- - -...------------------ _----------------------------------------_ ...... ----------------.............. ------------------------------------------------------ -- ------- - ----------------------------------------- ----------_--- -------------------------------------------- - -------------------------------- - - ---------------------- - ------------ ---- - --- - /I Inspection by:... - ....( - Dote `--------------------- ---------- Final - - yEN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F35 21677 REV.7/76 3M