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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: - ----------------------------- I 'r (Complete in Triplicate) Permit Date Issued_-h-Z 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 cmpliance with County Ordinance No. 549 and existing Rules and Regulations: , JOB ADDRESS/LOCATION-,,._ --------------- -----•----- ---- Owner's Name fl�.�---------- _ d. =_.-- - -- CENSUS TR ----------- ACT- - Phone Address--- Cit i R8 --- z� 3 3= -- - �- -- - Y Contractor's Name-A1 - v .Q License # -9�Z J] Phonecw �� 3 } {:. = Installation will serve: Residence E!�-* Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living un _'. _--'__--._-Number of.bedrooms.--�_--_Garbage Grinder. Size-_.- -------------------- -- --------- Water Supply: Public System and name---------- - ------------ ------------------------ P ivate 2�_' Character of soil to a depth of 3 feet: Sand ❑ Silt 0 Cla y ❑ Peat❑ Sandy Loam El 'Clay Loam ❑ i Hardpan ❑ Adobe ❑ -Fill Material_ es (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc.must be placed on reverse side.) NEW INSTALLATION: i(No septic ta6k -or' seepage pit permitted if public sewer is available within 200 feet,) PACKAGE REATMENT [ SEPTIC TANK O Size - ® - a - Li quid Depth ,. -- ---------- Capacity �at�- TYPe PkV,_41:4-0atarial ��- =---No. Compartments.'_-- -=�-------- ---=-� ( Distance to nearest:.Wel l.,-._-- - _ ,. =------- -_ -Foundation-= -40 Prop Line_--,!; T W . ----------- ------ LEACHING LINE ] No, of Lines-----__-_-�---------------- Length of each line...-- ____-.---._Tota! Length .-.._.�_-�7 --;,v S D' Box-----Ar^`f a Filter Material: YP Depth Filter Material-- ---_ -- <- I, Distance to nearest: Well.____-�50-------- --Foundation------ -------_--; _.Property Line------ ----------- - SEEPAGE PIT Depth__a�---Diameter-_.__ - -y Number 0x,.--- --------- � Rock Filled Yes ffi ,_ No ._. ----- Water TableiDepth ----Rock Size-------- �r �. --- ' Distance.to nearest:'Well_. ..-__ .._ ----- ---- ----------Foundation___--.-`�1. ---_-.Prop. Line___---- REPAIR/ADDITION (Prev. Sanitation Permit#--:- w ate ) -------------- ------------------ ----- - Septic,Tank (Specify Requirements)__.::- ------ _ = --` isposal Field(Specify Requirements)-------------------- - --- c _ _ _ - ---.-- ------------------------------------------------------ ------------------------------------� • -.---___.__.----_ _ - - ------------------------------ r {Draw existing and re4uired addition on reverse side) 1 I hereby certify that I have'prepdred-this application and that"the work will be done in accordance with San ty °' , Joa uin Coun � q Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local! Health District, Homq owner or licensed agents t signature certifies the following: F - "I certify that in the performan he-work for which this permif'is issued, I shall not employ any person in such manner as to b sub[ect to Workman Cope tion aw f California.',' ' Signe ---------- ------- BY%-------------------- ----- ----- ------- -------Owner -----Owner , r :.Title (If other' thanlowrier) .FF DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY_--• .- _ -- -- -- --- ---- --------- DATE----------------- ---- - -------- ---------- T IVISION OF LAND NUMBER. -- -- --------------- ----- _ : DATE ADDITIONAL COMMENTS - ------------------------ ............. - I' ------ ------------==------------------- -- -- --- ------------------------------ -------------------------------------------- ------ ------ ---- - -------------------------------------------------- --- / .F Final Ins ection b r ..- P Y ---- ------------------- -- - -----.-Date-� ---I----- fH ts 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fos 21677 REV. 7/75 9M