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' FOR OFFICE USE: FOR OFFICE USE: � APPLICATION FOR SANITATION PERMIT ----•----------------- --------- 6 ••-----------••-- (Complete in Triplicate) Permit No...�.%.�_--•.•-_-- ............................. ------- ""- Date lssued.._�C'��...7 „ ................................-------.................. This Permit Expires I Year From Date Issued Application is hereby mode 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 Ordinance No. 549 and existing Rules and Regulations: ]� JOS ADDRESS/LOC/ATIO�N_.1��76 ....... . ...... . - _- ---..__-.CENSUS TRACT......... . ............. Phone.......... Owner's Name..-- ICA - .. City. f zip- -- • - 7� Contractor's Name f _.� - / .- --_ .--- .---.License #.._ .8.. Phone------------------------------- Instollation will serve: Residencce❑ Apartment House.0 Commercial C] Trailer Court [] Motel- ❑• Other- Number of living units:--------..-....Number.of bedrooms....:;2. .Garbage Grinder............Lot Size................................ ......_ ........... Water Supply: Public System and name... ------------ .......>.* •-•--••-•------------ :-----• ••-----•-----• ................................................,...Private Character of soil to a depth of 3 feet: Sand [I 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 tank or see age pit permitted if public sewer is available within 200 feet,) 4_/ :'s "� ..........................Liquid De th..�.....------------.� PACKAGE TREATMENT [ ]' SEPTIC TANK [ `Size. p Copacity.11 Type_ Material..... .x...No. Compo nts,.;�-----------__-•. y ' Distance to nea est -Nell.___ _ ._ ..................Foundation._....�� -. Prop. Line..__?._.____. �_........ .Len-gth-of-e6ch1ir�s{._....:_.-�- _.._• -_ Total length ._:_._gd�" _ ----------- LEACHING LINE (• No. of Lines_ _____;_,_ r } D' Box-__--I-,_.Type Filter Material c�_! _.Depth Filter"N4aterial.._. X� .4--------------- •-----•-- . Z Distance to nearest. Well.:..-__y�{�l _ Foundation - .Pr' eeerry Line_....__, ...... ....... SEEPAGE PIT ( Depth...A�ADiameter........ _. .:. ._Number-_ ------------_..: R,ock'Filed Yes No❑ # Water Table Depth-------------- Rock Size.___. .�'� � 1- y Distance to nearest: WeIL_;.___ �'Q' __________._Foundcxtion_::.. .f ._..._. Prop: I /_ REPAIR/ADDITION (Prev.Sanitation Permit#--;_-•-----_--•_______________......_..............Date----_---.---•,_----_.__------...... 1_ _---_ 1 SepticTank (Specify Requirements)--............................................ ----......:-----------------•-••-------••-••...------...---••-----•----=-==------ .................. 41 1 u Disposal Field'(Specify Requirements)uirements).......:............ . i P a -----•---------------- ------•--__..__--- r� (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State L"w ,_and_Rules and Regulations of.the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: _ �.._ f - 1. _- ..I certify that in the performance of the work�-for which this"permit is'Issued, I shall not employ any person in such mangier as to become sub)eet. to Workman's Compensation Iows-,af.,Califorria.=' j 3 Signed-------------- — ---- .-_:..__0wner ..................... (if other thah'o"ir) FOR-,DEPARTMENT USE ONLY APPLICATION ACCEPTED ---• -:._:..--•..................................•-•----_DATE:_--. DIVISION OF LAND NUMBER...---- -- -- DATE ....... ------ _----------------- '\DDITIONAL COMMENTS- ----------••-•-•--..- ----------------------........-............. ...................:-------------- -------------- ......................................... ...... ........-•..................•......----••-----....•--••--- ...................... ..........................._................................ :`.--------........_._........ .......---------- ------••----•--•----------------•-----------------........._. ._..--- ... ........................................-................................................... ----------------------- ---•---•--.::•---•------•--••--•=--•------- --- - ------ - --------------=----------------------------------------------------------------•----_.----••- .. •--------•---..--- Final Inspection by=--------------- --- ' Date.- - _.____... EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FdS 21.677 REV.7/76 3M