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FOR OFFICE USE: '� FOR OFFICE USE: ` APPLICATION_ FOR SANITATION PERMIT ---------------------- -- ----------- '�r?n.!_p..'�-�. {Complete in Triplicate) Permit No. .. . Date Issued-f"Q.-130-7F ...................................................... 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: .. .-.-,CENSUS TRACT.-JOB ADDRESS/LOCATIO � -. - --._ ...... . .. - - -- - ---------- -Owner's Name..:- . ......... l Phone - -------- -------- Address. �.-- ... ..... ..... City... Zip Contractor's Name__ License #-...- - Phone. .. 711 �.. .l Installation will serve: Residence ❑ Apartme t House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other....... ---------_---------- Number --------_----• -Number of Jiving-units.'- /_ Number of bedrooms.—. -Ga b�age Grinder------------Lot Size... .�. 7,�.--..=- ... ] Water Supply: Public System and name- 1..a. ...... ---•------------- ------- --------- -------------------- Private ❑ h Hardpan Adobe Fill aterial�... ....If yes, type....................❑-- Y Loam (.0 i Character of soil tb a depth of 3 feet: Sand Silt Clay Peat Sand Loam Cla L (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank`Ror',seepage pit permitted if public sewer is available within 200 feet,} ,.• PACKAGE TREATMENT [ ] SEPTIC TANK [ ] x F size..... .-. .. ----._Liquid Depth..... .................. � Capacity... A?Type__" . '. .M terial.. - - .-... No. Compartments--- .-----"---------- Distance to nearest: Well-----�� ..-- Foundation.-Jr. . .............Prop. Line-... .o LEACHING LINE [ ] No• of Lines .:_......R-.............Length of each line........$....."..__._._ Total Length _.�. �._. -------- -------- r t D' Bo Type Filter Material-- - 02._ Depth Filter Material_..... -�---.-------;'----------- -------------------- - V Distance to Herres#: Well... "... - qa...Foundation....---_------------------Property Li Distance, ; SEEPAGE PIT ( ] De th.- .. Rock Filled Yes No p .....Diameter �.� 3....-- Number. ❑ Water Table Depth.---------- i..------.Rock Sl ze.... I .............. Distance to nearest: Well.--- Foundation.._ ..... .._._........,Prop. Line........-- REPAIR/ADDITION (Prev. Sanitation Permit#-------------------------------- ...........Date---..---:........--------.....- .. ------..---) Septic Tank (Specify Requirements).................."-. ------". ..... Disposal Field (Specify Re.quirements)----- -------- ------ - -------------- .. . ---------- ---------- -_-------------- --- � - ----- ------•--- .................------------------- - ---- - - - --------------=---------...------------------------------ •- •------:--------------- ---F----------.------- (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 County 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 personAn such manner as i to become subject to Workman's Compensation laws of California." Signed... . .. . .. ---- --- --- ------ - -----Owner By---------- ---- ------ � ......Title ------------- --------.---------- ............... ......------... If of er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... ...... ... ----..DATE ._ '/'.1."-7 ........... --- - ------ - -------------.------ DIVISION OF LAND NUMBER. - -- = - �. �:ri....:.:..............-.=.. DATE:...... . :..... ADDITIONAL COMMENTS -.-.--- - ....... ----------------------------- ----------- ----------- �+ ------•--- =- ---------- Final Inspection bd7 ""--: ` ------- -------Date - --------- -- Y- ------ ...--- F&S 2187V. 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT