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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------- ---- - {Complete in Triplicate} Permit No._�----------------- --------------------------------------------------------- Date Issued.l-)''-,7' ._-.7 ----------------------------_--- -------.--------- This Permit Expires 1 Year From.Date-lssued 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/LOC _[h ------- ____ __ ___ __________ CENSUS TRA _ ,[,� Af-e - --------------- ----- Owner's Name. --- �J f-. --------------------------- -----------Phone Address- - - - - --- �;----;- - - -------- -"=-- � - '_: f --- -----------city- ------------------- -----Z1P ,' --------- Contractor's Nam 9� -------------------License # -- --Phone-3,!55�PzO. Installation will serve: r Residence impartment House`❑ Commercial ❑ Trailer Court ❑ Motel F1 Other..................... 3 - Number of living •units:----------------Number of bedrooms ------Garbage Grinder---------_._Lot Size.----- -Z' _________________________ Water Supply: Public System and name------------------------------- ----- --------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Sift ❑ Clay ❑ Peat ❑ Sandy Loam flay Loam ❑ Hardpan ❑ Adobe ❑ fill Material_..-. -----if yes, type--.- r- --_- (Plot plan, showing size of lot, location of system-in relation to wells, buildings, etc. must be placed on reverse side.) [f� NEW INSTALLATION: (No septic tank or seepage.pit permitted if public sewer is available within 200 feet,) N. PACKAGE TREATMENT [ ] SEPTIC TANK [ ] f ,. Size--------------------------------------------------------- Liquid Depth.- Capacity--------------------Type----- --------------.Mate,rial_.----------------------No. Compartments Distance to nearest: Well---- <. _________Foundation -.-.---.Prop. Line____________________________ 4 LEACHING LINE [ ] No. of Lines----------------- ---..---.-.Length of eachJine,..y.w�,- -,_______._.__Total Length.-_____________________________ 'D' Box------------Type Filter Material--------------------Depth Filter Material---------------------------------------------------------------- _ 1- Distance`to nearest: Well.----.-_-----_,__,___-_.__Foundation_--.----.--- --- - Property ----- - ___.Pro ert ine----__.--._ SEEPAGE PIT [ ] Depth.---------------Diameter.-___.____.______._Number-�_----- '-----.----------- Rock Filled Yes ❑ No r Water Table Depth--------------------------------------------------- ----Rock Size------------------------------ Distance to nearest: Well-..----._-------------------- "'��Foundation Prop. Line-----------------.- REPAIR/ADDITION (Prev. Sanitation Permit#----------_--___------ ---------------Date.-.._----- -.--) Septic Tank (Specify Requirements)------------------------------- ---- ---------------------------------- ------- Field (Specify R quirements)--------- 1:��.-__ _ - - ``�-- �'p p -------------------------------------- ----------�---/L"� � - ------------------------------------------ --------- -------------- ---------- ------- ---------------- --------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed age s 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 manner as to become subject to Workman's Compensation laws of California." �qL Signed------- ------ -- --- - -----------------------------------Owner -----------------------------BY Title. GL� + (If other than owner) FOR DEPARTMENT W ONLY APPLICATION ACCEPTED BY-------.- ------------ - - -- DATE -----�. -' --- - _--- --------- DIVISION OF LAND NUMBER------------------------------------- _- ----- -- .----------------- ---- -DATE------- --- ----------------------------------- ADDITIONAL COMMENTS --------------------------------------------------------------------- - -------------------------------------------------- -- ---------------- --------- ------- ----------------------------- ------ -- - - ------ ----- - Final Inspection bY:------------- ------ -------------- - 7p--- -- Date / ---7--1---------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M