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FOR OFFICE USL FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT a Permit ----------------- ------------------------------------- j (Complete in Triplicate) � s Date is . /- ., 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#1 unty Ordinance No. 549�and existing Rules and Regulatio This application is made in compliance with Co " € .......CENSUS TK, qd c JOB ADDRESS/LOCATION_. .,.- --- _ Phone-l- r Owner's Name.._ : . Address--------------- - Y "` 1 ---- �' �-�---- -- Phone---- --- ------------ --------- :z -_ = License # � -- Contractor shame---- ---- --- - - -- --- at Installation will serve: Residences Apar#ment,House,0 �-Commercial❑ -Trailer Court ❑ z a Motel = =y 5 _ GLS 1 i Other -Lo# ize- - --- -- y Number of living units:_____":_ _=_-_Numbe—.oi' bedrooms _. .Garbage Grinder__ . --- -- t ---------Private Water Supply: Public System and name___ -. Peat Sand Loan�la Loam Character of soil to a depth of feet: Sand ❑ Silt❑ -Clay ❑ . ❑ Y Y l Hard an ❑�' Adobe ❑ Fill Material ---= .-If yes,type (Plot plan, showing size -of IOt, location of system in relation to wells, bungs;'etc. must be placed on reverse side.) NEW 'INSTALLATION: septic t-nk,or,?s-eepage`pit permitted if public sewer is available within 200 feetp h 4 _Liquid Det ._�-3 PACKAGE TREATMENT [ ] SEPTIC,,TA-NK L'1 ' } � , 'Capacity J TYpe Material .rte- °-No. ompartments ------ ----------- � . E C ,,j- y,,L• , .. � � .�~� t -_Pro Line." � -- --- s: { Distance to nearestWell"_ -"��- Foundation.__ _/�� p• � Y_ - Lengt.h ,of each Ijiie y -- Total Length-_ + LEACHING LINE L .l Na. of Lines :_ r 111. _. ., -- -- -- --- ----------- _Ty_ - -- '��"` Depth Filter Material....... � -- D' Sox..-_�_ '...Type Filter Material -- 1' ,-,• _ F _ �- Foundation - ine Distance to r earest:Wel!�. 7e, Property;L' k Fill e N -SE GE PIT L h Depth ? - Diameter Number = Roc ,. Yes o . Water Table.Depth.-- -------- r� Rock Size �� : _ , r p, Li _ { earest:Welly° -Foundation. L="%a" P o Line_,, i i Distance;to n r.' Date --------------------------------------------) R t --------------------- REPAIR/ADDITION (Prev.(Prey. Sanitation Permit#-_.-----'----- - - - - --- - . ..-.� Septic Tank (Specify Requirements}-_.-_:- � --- ---- -- --------- ------ -- --- -- C -- - -------------------------- Disposal Field (Specify,Requirements)-------------- --- -- ----------------------------------------- I ----------------------- - - __ V r ,. ---------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have 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 t signature certifies the following. "I certify that in the performance of-the work for which this permit is issued,'l shall not e+nploy any person +n suchyman�ner'as to become subjectlo`Workman's}cbmperisat-ion"laws-of"'Califorrtiia:" } - Own - -- --Signed_------ '- --------------------------- - (If 'other'Chari.owner) OR DEPARTMENT USE'ONLY ,.. APPLICATION ACCEPTED BY_..-- - --------- --------------- " " - == DATE = =----- -------- ------- _.-- DAT = - DIVISION OF LAND NUMBER.ADDITIONAL COMMENTS---------------------- ------- --- ----------------------------- _. --- - --------- - ------------------------------ Date —�— - Final •inspection b -.". ---------•--•-- _------- -------- Y'-- '------ -' F&S 21677 REV. 7/74 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT