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FOR OFFICE USE: U� t APPLICATION FOR SANITATION PERMIT 'FOR OFFICE USE: (Complete in Triplicate) elk Permit No._;7e-/-I0_$_- .......... ......... This Permit Expires 1 Year From Date Issued Date Issued_/. :-,/Z-,7 � Application is hereby made to the.San Joaquin`Local Healthtpistrict-for a permit to construct and install the work herein described. This application is made in compliance wVith-Caunty C�rdinaiice'No.'549 and existirig Rules and Regulations: ZT JOB ADDRESS/LOCATION ---' -- ---- ------.CENSUS TRACT- --Y - i Owner's Name-- -'- ------ Address- ` °- . --- Phone ' -- --- -------------- f :- - --- - ------------------ --City ' p ' . Contractor's Name " zi --------------------- r. -- ------ - -- ._License --Phone--- ----------- �---.---'- - ` 1 ,. + m�.. .. ... 4 ' 4 Installation will serve: 1Residence Apartment House.❑ Commercial ❑ Trailer Court. ❑ 1. Motel-❑ /Other.:-= ''= .-a ----- ------------ --------- Number of living units:_-__: .- ,Num�erof bedrooms "_Garbage Grinder---------- _.Lot l Size--- Water Supply: Public System and name__--# __ ___i_- - - ------------- - ., --- ----- : Pnvate ---- - Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ # Hardpan ❑ -Adobe❑ Fill Material___.."- ' lf y_ es - , type '---.----------------- (Plot plan, showing size of lot,=lo4catipn of sysfe`m in relation_to.w.ells, buildings, etc.must be placed on reverse side:) r NEW INSTALLATION: •�(No septic-tpnk�or seepage:pit permitted if;pUblic sewer is available within 200 feet,]. # PACKAGE TREATMENT [ ] SEPTIC TANK [ .l -;Size___° ------ --------"__ -'__ - ; --Liquid Depth - ------------- --- --- - t . . . *. .Capacity,.._ , -:T e k YP Ma#eria!__.=- __-- _-. .-No. Compartments-_- _. i . Distance�to nearest.Well -_ - --- Fo d t un a ion ------ Prop. -Line_ LEACHING LINE [ ] No. of Lines_- ,_._' --- ; ------length of each lana ,- _._- Total.Length.--------. --__ ------- ' i a 'D' Box_ __- Type Filter Material_____________________Depth Filter Material______-._,`_-__ :....... .... ,- .. ------------------ - --------------- -------- Distance,to nearest: Well __ Foundation __ 1 Property Line ' -t SEEPAGE PIT [ ] Depth................Diame:ter--------- Number---------- ----------- .= ------ Rock Filled Yes ❑ NoA❑ Water Table Depth._- ---- ------- ------- - -Rack Size Distance;to nearest: Well-.'-----`------,--"'---------------- Foundation__ ' _-'- Prop. Line-------------------------c : --- REPAIR/ADDITION (Prev.-Sanitatibn Permit ___'-___.__ . --------- -.--Date { ] Septic Tank (Specify Requirements)----------,-s'--------------- ------------ -------- ------------=----== = � D4osFiel Specify Requirements) L�- '1 �X�- --------- --------- ----------- -------- - (Draw existing and required addition on reverse side)-'- T 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 Wealth District. Home owner or licensed agents signature certifies the following: " "I cert: that in the '! following- certify performance of the work for which 'this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation _laws .of California.'? _. 1 _ Signed--------- ------------------=- r ; By J. =--------::: (If other than _ ``,R�- Title-----= •- owner} ---------- --- ?1... FOR DEPARTMENT USE ONLY" APPLICATION ACCEPTED BY---- - - ----------------------------- -- -----------------------------------DATEL?- --------------------. 1 :_-_ __ � •'s.-A' DIVISION OF LAND NUMBER " - ; --------'-- --': ; --------------------..:_ ATE----------------- -=--------- „ = ------------ ADDITIONAL COMMENTS. ---- ---------------------- ----------------------- ----- .' ; �� -----=----------------------------' ------------: ` = - ----- ' ------------------- ii -' •-• --------------- ----------- - �-' - �------------- Final , ------- ---'-------- - ---------------- ------- !ns ection•bY�"--- - ------�- N JOA ._., Date/-,;L EH 13 24 i QUIN LOCAL HEALTH DISTRICT F&s 21677 REV. 7/76 3M