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i FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Y ' ----------------------- (Complete in Triplicate} Permit'No..7.:!"`43. - '. -------- --- -------------------------------------------- Date Issued&_—�_-?_9_ ..--.------.-.._--.-.."----------------_..___.____.__.__ 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/LOCATION ---------.CENSUS TRACT_ [�"� z. 3 d Owner's Name--------------ce-q --- ------- ---- --------------------------------------------Phone-------- -- ------------------------- Address ----_----c _3 b-------��` City " Zip - _ a -..- f' ---------------� -"�'?+ZLicense #.3�.��.� Phone--------------------------- _- -- Contractor's Name""�" "" ��---��-__ �� Installation will serve: `. ; Residence ( Apartment-House ❑ Commercial ❑ Trailer Court❑ k -. .l -.y..._;....... Motel ❑ Other Number of living units:___`; ------Number of bedrooms__-__Garbage Grinder_.._- -Lot Size-----------------------------------------_---.-------------- { l Water Supply: Public System and name----=------------------------------------------------------------------- ------------------------------------------------------------Private Character of soil to a depth of 3 feet: and E] Silt E] Clay F] Peat ❑ Sandy Loam E] Clay Loam ❑ Hardpan[ dobe❑ 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.) i NEW INSTALLATION: (No septic tank '6r seepage :pit permitted if'public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] :-SEPTIC TANK ( `] Size-------e-------" q p -t - CdpacitY�, . . Type Material` - ----_-----,No.-Compar-tr ents�w------------ Distance to nearest: Well-------------------------------------------Foundation-------.-.----------------Prop. Line-------------------------__-. LEACHING LINE, [ l No,_of Lines________ _____ ____",,,._,_„_-.Length,of each line,.._______._--.-__---.--------Total Length..__,.._.__ „__.__-___.._..------.------.-- 5 'D' Box--.,t-------Type Filter Material-------=------------Depth Filter Material.-- -------------------------- . CO ` Distance#o`)nearest: Well----------------------------Foundation---------------------------Property Line----------------------------------_ SEEPAGE PIT [ ] Depth ------------ -- ----Number-------------------------------- Rock Filled Yes ❑ No ❑ G i . Water Ta'ble'�D'epth------------------------ ---------- ----------.Rock Size-- ------- ------------------- Distance to nearest: Well:"...---- ------------ -----------------:-----.FoZnE[7 Prop, Line----------------------- REPAIR/ADDITION ]Preva Sanitatio�-Permit#.-------:--------------"-----”------ ------i --'i------.Date-------------""---�---------------- -----) r Septic Tank (Specify Requirements)--------------`--------------------------' ------------- -------= ----------------- --------------- Disposal Field (Specify Reuir',ernen#s "' ` -µF - ------------------------- jj ++ 141 ------------4q- - = ci"'-- --- 1 - = P --- $-- ------ ------------ ---- : ------------------ ------------------------------------- -- -- -- -- ---------------------- ' ---- ------------------ -------------------------------- ----- j i (Draw existing and required addition-on-reverse-side)-_, l 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: l "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." : .-. ----------- --OwnerSigned By ----- ------- --- - Title----44'� --------------------------- --- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY...` - ----- DATE. ----------------- ------ -- ------------- DIVISION OF LAND NUMBER.-------- ----------------------------------- DATE-___ ADDITIONALCOMMENTS------------------------------ --- ----------- -------------------------------------------------- -------------••--------------- ------------ --------------- ---- --- ----------------- -- ------- ---- ------------------------------- ----- --------------- --------------------------------------- --------------------- ----------- ------ --------------- ------------------------------------------------ ---- ----------------------------------------------------- _ -- - - - ------------------- - -- Date...-__ Final Inspection b /" -�� ------------------------- ' -""' - EH 13 24 -" F&S 21677 REV. 7/76 3M SAN JOA,