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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit Na...7�-'�-�lJ.�- (ComIf tplete in Triplicate 11.................................. .......�..�.... Date Issued... ..,,.--.-"..--_................. This Permit Expires 1 Year From Date Issued described. Application is hereby made to.the San Joaquin Local Health District for a permit to construct and+ install the work herein This application is made in compliance with County Ordinance N . 549.and %sting Rules and Regulations: CENSUS TRACT.................. ....... ... JOB ADDRESS/LOCATIO - . ......Phone..:-- -------- Owner's Name....._. ... Address.... City -- Zip. _... ��.,. .... .-- " .---- -- ----------- ---- "------- ], y Contractor's Name. ...... - . .............. . . .License #.'-wir 7 -. .Phone. rr/� � rf------ Installation will serve: Residence Apartment House F-1 Commercial E-] TrailerCourt ❑ M tel ❑ Other...... <�r. _ �.- Number of living units:....... ......Number of bedr ns.....:Garbage Grinder.:-----------Lot Size..--6.D. . \ - 1/9--- . Private Water Supply: Public System and name. Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑' Clay Loarp. `` Hardpan F-1Adobe❑ Fill Material- ---. ....If yes, type_•--------------- ; I -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) rN NEW INSTALLATION: (No septic.-tank. -or.seepage p-it ,permitted.-if-public-seweerr is ovoilabie within 200 feet,[ " 1 SEPTIC TANK [ ] Size. -.Y 67-✓�--/P---------- ----..Liquid Depth.'--* PACKAGE TREATMENT [ ] �` " . afar% No. Compartments..._//L -- -- ----- --- Capa6tyType. ... .... .. -----Foundation.----f .-.�.�..W.J. Distance to nearest: Well...... .. p. Line LEACHING LINE [ l No. of Lines -. ......"...............Length of each line.......j-l)-6)......-.---Total Length .L-P-C ... --. ....I 'D' Box...._._..--Type Filter Material..-... Depth.Filter Material --------- ----- • ---...... r .Property Line.... :- -------- Distance to nearest: Well__..1". - oundation.-.-.-.. p----- P Yf IV,� �p _ Rock Filled 'Yes No �T [ ] `Raptl ...............Diameter...-.-----.---- _ Number... oc ..-. __. ---.... .Water` Table Depth.-"---"------------------------ ---- - i------Foundation.....--- .._.Prop. Line------------------ ----Distance to nearest: Well----------------------------- �--- - , REPAIR/ADDITION (Prev. Sanitation Permit#.................._. Date...- - ------- ---------] Septic Tank (Specify Requirements)--------- ----------- - - � �. t Disposal Field (specify Requirements)..............:..• -- -. .............................•- -------- ------- L .a.. - .. ... ------- _ .............................". ......... _..-_.._".. _.._". r--------------------- ---".._............._.. ...--.....- ......_.7 "r-,_...__ _ (Draw existing',andlrequired addition on.reverse side)- E n Joaquin County I hereby certify that I have prepared this application and that the work will be done in accordance with Sa Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents 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 subjectito Workman's Compensation laws of California." Signed.....----- -.. ........... .....Owner Title.-- ---- i if other than owne vim^ FOR DEPART NT USE ONLY ?- - -. APPLICATION ACCEPTED-By----- _ _.. ---- --- �- ----.._ ..-.... ......... ........DATE .....�-� � - ... .. DIVISION OF LAND NUMBS ------ ---- ; .... .... ......... ---- �� ..$ ...... ADDITIONAL COMMENTS. --- .. l.�7LI�7..w.-- - -------- � ------ -- �-�-- - -�-�- - ----.... .............. .� ---- -- ---... - �� ..../..¢_ ..... ... ..............I------ ----- - 7 ----------------•�----------- �--- ----- . Dare..._ .._. ..........---...--- -.. 71 Final-Inspeci�ion b } F&S 24677 REV. 7/76 3N } EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT