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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------- (Complete in Triplicate) Permit -------------------------------------------- ------ ---- Date Issued_1--3_-7- 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 Ordinance No. 549 and existing Rules and Regulations: / JOS ADDRESS --- ----------CENSUS TRACT-----------------------------.... /LOCATIO ------- ----�h�-�_._C®_I- -----�--------i� `�=--��---- Owner's Name_--- ----- -- -- --- ------- ----- ---------- ---- -------- one----- ----------------- -P .Ci ------Zi ------------------ ` � / City- - p Address---- -�__..------- ---------------- ----- - -- - - ---- --------- - ------------ Contractor's Name ------- -- ----- ----`-------C.... .. --License --Phone Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------- ----- ----- ---------------- Number of living units:___.__/______1qum.ber_oLbedroom s__-�Ja_--Garbage Grinder_-.---------Lot Size----- '_Q- --------- -----_________________ Water Supply: Public System and name------------------------------------------------=----------------------- --------------------------------------------------------.-Private Er_� 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 tank or seep ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC 5ize_ / Liquid Depth_____ ------------- Y Capacity.A-0-------Type- ._--------------------Material.___ –l/u- ---No. Compartments-------- ----- Distance fo nearest:Well.-------- �p-----------------------Foundation-----/.-;%--------------Prop. Line- --______-_.____- LEACHING LINE [ No. of Lines--------- Total Length --- � Length of each lineQ g -------------------- 'D' Box_____ -----Type Filter Material_ _5.�_ -----Depth Filter Material--__-. _�!___ .______ ____________________ -- / / / Distance to nearest: Well____ )- _______ ___Foundation_______/_�_____-_._-___Property Line______--�_ - SEEPAGE PIT Depth--z+r.___Diameter_______-�33'�Number_.._________..__............... Rock Filled Yes L!� No ❑ . Water Table Depth----------- O p--------------------------Rock Size----- ?------------------ / Distance to nearest: Well..._________- 0-- ----------------------Foundation-.---1_ -----------Prop, Line_____________--___-__----- REPAIR/ADDITION (Prev. Sanitation Permit#___-___ _____________________________Date___.____..-___._----------_--------------_-__) Septic Tank (Specify Requirements)- ----------- --------------- -------------------- ---- ---------------------------------------------- DisposalField (Specify Requirements)---------------------- ----------- --------------------------------- ----------------------------- -------------------------- ------------------------------------------------ -------- ------------------------------------ ---------------------------------------------------------------- ----------------------------- (Draw ---------- --- (Draw existing and required addition on reverse side) 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 Co ensation laws of California." Signed------------------------------- ---- Owner - ----- ----- --- ------- BY-•--------------'-------------------------- Title ------ ------ --------------- ----- (If other than owner) FOR DEPARTMENT USE ONLY 77 Ir APPLICATION ACCEPTED BY---7 l - --------------------- ---------------------DATE " DIVISION OF LAND NUMBER. --------------- 1 ------------------------------------ DATE ADDITIONALCOMMENTS---------------- ----------------------------- ------------------------------------------ ---- ---------------------------- --- ---------------------------------- ------------- --------- ------------ ----------------------------------------------------------------------------------------------=-------------------------------------------------------------------------------- --------------------------------- -----=------------------------------------ ------------------------------------- ------------------------------- - - - -------- -------------- - - - Final Inspection by -------------------Date J f EH 13 24 SAN JOAQUII� LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M