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FOR OFFICE USE: FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT ------------------ ----------------------- 7 7 - �o- Permit No.__-�, 7 in Triplicate) -- --------------------------------------------------------- Date- Issued_r -------------- 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: JOB ADDRESS/LOCATION_.Z_ _ - --------------- -------- ---- - CENSUS TRACT-------------------------- ------- - ----- Owner's Name... _ -�_y } _ _ - _ r Address _f- -� 2 - ----:----- City-- -------------ZiP Contractor's Name.. �- ---------. tin .-license # _____________��__.P :Lhone.�� `f _. Installation-wil-l_serve -��* —R � -� ' � - esidence-PI ❑ Commercial ❑ Trailer Court ❑ E _.Motel_❑:_..:.:.Other-- .^,_- --- -_- t - t Number of living units------- ------Number of bedrooms'.'-_-.Garbage Grinder------------Lot Siz6--------- -- - -------------------------------------------- Water --------.--.-______.____ ______--_. -Water Supply; Public System]and name-----------= --=-------------=---- --------------'------- _._ = _.- Private 6 I - --- Character of soil to depth of 3 feet: Sand ❑ :Silt❑ Clay ❑ Peat Sandy Loam ❑ Clay Loam ❑ = t Hardpan ❑ - Adobe:E] Fill Material........----If yes,type---------------------------- --- k (Plot plan, show,iqg size-'of lot, location of system in relation to wells, buildings,'etc.Must be placed on reverse side.) tt� NEW INSTALLKTLON: '.(No septic tank"or seepage pit permitted if public sewer'is available within 200 feet,) ° PACKAGE TREATMENT, w •" [ l �� 5EPTICTANK [ ] Size---'-'---- --- - ----- --------------------------Liquid Depth-'----------------------.- [ ` , -.Typa--- MCa acit )�e-� aterial-------------- -----._Nof. Com artments._'__._'L-------------_- .� Distance;to nearest: Well-------1- '_ -' -----------------------Foundation.- Prop. Line----------=----------- ----- LEACHING LINE ] r No.'"of Linesk_________________ ______Length of each ling_ __ - °------Total Length._ _ f D' Box Type Filter Materiale-e -__-Depth Filter �yi I .'-----Foundation. . .,Material_---�_ _ -_ ._-__ ____,__ ca#o nearest: l __.£-----------------------,Property Line..---- .---------,- -. - eD ameter.-_.___._ NumberSEEPAGE PIT DeRock Fillet) Yes.❑ NoEf - .. -� , I Water Table Depth---=-------------=-------------------------- ------i--- Rock�Si -- ------------- -- ------------------------ _ R Distance to nearest: Well_ --_----------------'----____-- ' Foundation--'.------ ------ --"'';-.Prop. Line_------------------------ [; # { REPAIR/ADDITION (Prev. Sanitation Permit#----------------------°-----_:--------:_:_-`--__ Date-----?. -------------------------------11 Septic Tank (Specify Requirements)------ ------ =------------------ _ -- bisposal Field (Specify Requirements) - -------- • ---- ------ ------------------------------ ------------------------- ' ----------- ------------------- ----- ---}--�--!----- --� "' _ ' \. .- .------_ - _ _ - --`-- -------- -- --. ... F. - ------------------ - -- (Draw,existin'g-and required addition on reverse side) � f ' I hireby certify that I have prepared tis application and that.the work wili�be�done in accordance with San Joaquin Coum the San Joaquin'Local Health District, Home owner or licensed agenh Ordinances, State Laws, and Rules) and Regulations of 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 mrnner_as- to become subject to Workman's Compensation: laws of California." . Signed �!� i -- --- - - ------- By------- By------- - - ' 4 Title j_ __ -(If Ether"W6h':awrier) - F R DEPARTME USE ONLY\ - APPLICATION ACCEPTED' BY,'------ -- /- ' -=- -- --DATE { DIVISION OF LAND NUMBER;--------------'-------- - DATE--------------- ADDITIONAL COMMENTS-4 r = -• � .,. - --- =` -------------- _ ------------=-------------------------- -- -------------------=----------------------- -- ------=------=--------------------------------------- ------------ ------------------��--'---------------- ------ -- -----:---------------- ----------- ------------------ ------------------------------------------------ ------- ----------------------- =---------- -- - -------------- ------- ---- - - --- -------- ---------- ------------------------------- ------- - - --- Final-Inspection by:.. - _ �� ------Date ' s--_ ._... EH 13 24 a SAN JOAQUIN LOCAL HEALTH DISTRICT _ - . ras 21677 REV. 7/76 3M < � T