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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERK low 7T' (Complete in Triplicate) Permit No. •••---•----• - - This Permit Expires 1 Year From Date Issued Date Issued. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descriL This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION �Lrj ��' /R C 7_1411iF WIA Y R/9 ,L C'C.11' ./-4'/t�f�.CENSUS TRACT _... ._. .. Owner's Name _.. .......... . Phone -.33.y....../may _ .. . Address_ /` Nle City......... Zip .... . . Contractor's Name C W//GR, License # _.. .. _ Phone_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other Number of living units: _. _ Number of bedrooms -:3 Garbage Grinder V4-Y .Lot Size_ Water Supply: Public System and name _ _..__-. _.._ .. ... Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ 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 tonk or seepage pit permitted i public sewer is flvailable within 200 feet,) PACKAGE TREATMENT 1 [ ) SEPTIC TANK "' [ ] _ Size X _/� / Liquid Depth..... 7- Capacity J �. )Ot'- ' / l �. �"N ompartments _ ... ... Distance to nearest: Well.. C� Material foundation ..- � C ' ./ Prop. Line LEACHING LINE { No. of Lines G''tiC ._... ...... Length of,e! h line .... _C. Total length 'D' Box ,X-- Type Filter Materials c,,:_ Depth Filter Material. .....� . -. ._ Distance to nearest: Well.. .... .. ... . Foundation..../........... Property Line . .>S. SEEPAGE PIT > Depth S Diameter. _�.. 3 ' Number Com ::_------.. Rock Filled Yes No Water Table Depth......- . . ...............Rock Size_ .. Distance to nearest: Well. _-... _ _.._ . ...----Foundation..... . Prop. Line REPAIR/ADDITION (Prev. Sanitation Permit#..... ._.. ......Date.............. _.) C Septic Tank (Specify Requirements) - ......... 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 Cour Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed ager 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 to become subject toWorkman's Compensation laws of California." Signed:.:.: i ._.r.. =s. ..: _ _ _ _._ _ _ Owner J G By------- Title _ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY......' _�.. .. �`Ir __... .. .DATE 1 DIVISION OF LAND NUMBER .. __.. _ . DATE --- _.. ADDITIONAL COMMENTS _.. ....... _ . .. �1_ _ Final Inspection b ��''�=�L � ... . Date. . . y:. . . EH 13 24 SAN JOAQUIN LO L HEALTH DISTRICT F8S 21677 REV. 7/76