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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- --------------------------------- -- --------- Permit (Complete in Triplicate) ------------------------------ -------------- - Date Issued__a=` __—Z/ This Permit Expires 1 Year From Date Issued 'G 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 County Ordinance No. 549 and existing Rules and Regulations: -- JOB ADDRESS/LOCA_TION._.! It ;- _._CENSUS TRACT -_-- ---------- ----- - ' , k "r _,_ ^ � Phone _ Owner's Name.- - - _ M -- ; +7 �� 1'. Z i P Address_ d-: ._ - I 4 ---- ----- ------ City Phone ?_3 lane__. Contractor's Name ---r -- 07111--- -- - ___._License #_ w t � House Commercial Trailer Court ❑ Installation will serve: a ResidenceApartment ❑ ❑ ..._ - Motel.`❑--'Other_--F ------------------------------ _------- t �. �. Number of living units:._-- -------Number-of.bedrooms__,�_ Gar.kage Grinder .___.Lot, , w..e Water Supply: Public System and name_• -:___ ____ -— ._.------ --•--- Private ' pp y: ; Character of soil to a depth of 3 feet: Sand E] tSilt E] 'Clay ❑ Peat EDSand-y Loam El `Clay Loam Hardpan E] a' �n 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.) 1 _ ublic sew r is available within 200 feet,) PACKAGEATREATMENT [[ ]o' SEPTIC TANKr seepage= it` Sizetied"E - :___--.Liquid Depth._._____-------------'_._ septic' � , P tP P - ;------ .._ Capacity -��TYPe='`t .- ;_._ - ._MatariaL � rte'No. Compartments i a b.istance,to ne.arest:.Well_:_ --- ---- =-Foundati _�. :t. - ---. op. Line_-_. �--�-, ----- Pr LEACHING LINE: [A] No..of-Lines:_ ----.___--:-Lengfih,of each line--------- - -----------Total' Length _: -. � - t j.. D' Box--.--/_____Type Filter Material3��r. � Depth Filter Material ------ _._ - -------------------------------- + r , A. . . . r ' :Distances to nearest: Well /__ '- Foundation-r- --_--- Property Line ___S r ... ..� .. a 1;. tit R ., 1 �. 'Depth No El� ------ Rock Filled Yes ❑ SEEPAGE PIT DePth---- - tiameter, = -' ---------Water Table De h___. - -------------------------------- --Rock Size Distanceao nearest:Well i --- ----------------------- --'Foundation__ _.. Prop. Line ' r t REPAIR/ADDITIONA-Preva S ni"iation'Perm-it#'74-- ------ #----------- -.Date -"• ------:-----] Septic Tank (Specify Requirements)__________ _ _______ ._ -------------- 'l I Disposal Field(Specify Requirements)------------------------ ---------------- -------------- = - ' ------ - - _ _ .. .. - ,,, '(Draw existing and-ed 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 j 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, 1 shall not employ any person in such manner as to become b- ct to Worms a 's Compensation claws}of California." r . ` S Signed=--- - �----'--/Y�- -- ------- ------/------- tner le- ------------------------------ --.- i (Ifother thanowner) . r r FOR DEPART ENT USE ONLY APPLICATION ACCEPTED BY --------- - -- DATE - =------------ --- - --° - - DIVISION OF LAND NUMBER.------------- -- DATE. - ADDITIONAL COMMENTS---------------- -------- ----- --------------------------- k - -------------------------------------------------------- - ----------------------------------------------------- ------------ ----------------- ___ _ _.___ _____._____ 3 = _ ------------------ i- ------------- - - ---------------------------- - -_---- ------------- - -- -/-p' Final Inspection b--------------- --------_--------------------- - V- � �_ �, ` : ate--__ `"" ."`� � � F&5 21677 REV. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT