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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT `p ---- - ----------- Permit No..��----/7 {Complete in Triplicate} -- --------------------- Date Issued-//-,6 7;,7 � ------------------------------.-------------_---___-_--_ This Permit Expires I 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--- fO- --_ ^ -------------- CENSUS TRACT Owner's Name------- ------ = rP,1:'1CCJ Phone------------------------------. . . --- --- -. / -- Address.---------- - = F.�--- --- min-Bf. - - City" "----------------------- Zip _ ' -----------------------License #__�Z_F_ZZ_� -------------------- --.Phone.____--__ Co'ntract'or's Name______ --- Ad_z� ---- Installation will serve:'- ' ` Residence [/ Apartment Mouse❑` Commercial ❑ _Traiier Court ❑ ` Motel ❑ Other------------------------ 4 Number of living units:-------�,------Number of.bedrooms---- _._Garbdge Grincl&r..... �_-Lot..Size-------------- -_--�-- ------------------------. Water Supply: Public System and name------:---! ------ ' `' ' _.. � �'�e = ------- _Private 0 CJ Character of soil to a depth of 3 feet: Sand E) 'Silt E] Clay ❑ Peat El Sandy Loam ❑ Clay Loam ❑ Hardpan feet: a Fill-Material_..._. ......If yes, type------------- ---_______________ - (Plot plan, showing size of lot, location of system in relation tow r ells, buildings, etc. must be placed on-reverse side.) Or NEW INSTALLATION: .(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK —Size� ._�_�-'-.-.�� ------Liquid Depth--- =__________________ _� A Capacity 4 Q Type c -ter Material =-----No. Compartments ------------------------ -- Distance Distance to nearest:WeIL,.-_._�_ __��©_ __-_____`_. -•Foundation-______f-40 �- ------------------- - � �__---Prop. Line LINE [W No. of Lines._____._.________________ Length of each.line--------- ------..Total. Length __gi p. "_ .-----.-_-------.__ `D' Box--:--_�"'__Type Filter Material-- -- _---.Depth Filter Material-- / -- --------------------------------------------- e Fi I , Distance to nearest: Well-------_5 P^ Foundation_-____._�-©_ ---Property Line--- -----------------. Depth----1I�+ #ec-- �rI'1�J_�NUmber---:.._ " t Rock Filled Yes RNo}❑ ------------- s� r t Water Table Depth - -- =---- Q_ ---------------------------Rock Size ---------------------- Distance to nearest: Well-M.------------5� ------Foundation,-,- ____.Prop. Line.__. ------------- REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------:-------- ---- Date-------------:-----`-----------------------"----� Septic Tank (Specify Requirements)---------------------- --- ----- ------------------ e Disposal Field (Specify Requirements)----------- -------------------------------=-------------------- ------------------------------------------------- ------I--------------- I ------ --------------.--------------------- -------------------- ------------- (Draw existing and required addition.on reverse side) 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 Regulation§ of:the' San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: . "I certify that in 'the performarice of the work for which this permit' issued, I shall not employ any person in such manner as to become subject to" Workman's. Compensation' laws of California.'.' Signed-- ---- --- Owner Y =------:--- - Title =----- --- ---- _ (If other than owner) ► OR DEPARTMENT USE-ONLY. APPLICATION ACCEPTED BY --- _---=----- --------------------------------------------------------------DATE.// ------ ------------------ =--- DIVISIONOF LAND NUMBER ------ -------- - ----------------------------------------------------------------- ------DATE.- --------------- ---------=------------- ADDITIONALCOMMENTS--------------- ------------------------------------------------ --.------------------------------- ------------------------------------------------------ ------ --------------------------------------------------------------------------------- - - k _____________________________________________ _ _ - ____. _____________ --------------------------------------- ------------ ---- Final Inspection bY:---- r-�` U 0 --------------- Date 1� g EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M