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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit ------------------------------ ------------------------ (Complete in Triplicate) --------- -------------- Date issued_ This Permit Expires 1 Year From Date Issued Application is hereby made #o 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`ADDRES5/LOCATION .71._ 2 - - O�-------------------- CENSUS TRACT t ---- ------------------------------ JOB ' ' one ------ ------- Owner' Name= - ' --------- s " A ii r 1 Y Cit -- ------------___-Zip----- ------------- ---------- ------------- Address-------------- 6 " Y..= &�� i.f � ------- ' Contractor's Name = License #_. '�� Phone _ F I Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court-L] r ...,.Other----- --- - ---------------------- ------ - ' . Number of.bedrooms-._�Garbage Grinder- __ ----Lot Size:. .._ _. .. Nulmber of living units: ___. ______ R s -; ---------------------------------Private + Water Supply: Public System and name------------- - -- = ❑ Character of soil to a depth of 3 feet: Sand ❑' Slt E]--Clay ❑ -Peat []_�--Sandy Loam ❑ --Clay Loam ❑ Hardpan Adobe [] Fill Material__.__;_____-If yes, type ---'--•---- --- ----�-- � 9 (Plot plan, showing size of lot;,location of system-in relation to wells,.buildings, etc.must be.placed on reverse side.) i NEW INSTALLATION:" '`[No'septit tank'or seepage pit permitted if public sewer is available within 200 feet,} } i. SEPTIC TANK [�]. -L;�.,�' Size = Liquid Depth - - - PACKAGE TREATMENT [ 1' '' - ---._ _-- _ __No: Compartments--,.____ - --- I'- Distance.to nearest: Well -:----- ---Mate`rial . ' _-- �-- $ ;: j Ca acit -`T e_- -•---=-- p: Y -- Yp ' = -------- '------------==Foundation -:,i_Prop. -Line--------------=- = ` ---.-:.Length of line.. "�------ ''. °.Total Length.--==_ ' ----- LEACHING LINE L A... .No, of Lines-----------------------' t , ; ------------ D' Box Type Filter Material------ -=-----Depth Filter Material- ---------------- ; i., _ Distance,to nearest: Wel!_;.__________.___...._._--Foundatianu l--------------=-Property Line_-___._-- ------ r' ock F ed . Y ❑ N ❑ i . Diameter-- --- -- ---Number..................... , -- ; R ill es of C SEEPAGE P11 [ 7 Depth._. t -------------- Waiter s T Table'Depth-------- ---------=------------- Rock Size_-_- - = .. "'Found 3.- - .___ - Distanceaoiriedrest 'Well_______________'--- Foundation._ --_ Prop. Line_____) ___.:_.___. -- --=-------- ---------- W' REPAIR/ADDITION (Prev.,Sanitation Termit#--"'- - Date-'----_-_ J Septic Tank (Specify Requirements)-----' -- --- = -------------------- - -------------- -- == r� Disposal Field [specify Requirements).__,----. ,Y-4 . -, , - -- - -# ----- - 4 , - ---------- - - ----- d n------e-i---------- / ------ ' ----- itioon reverse side) exda I hereby certify that:11 have prepared this application and that the .work will-be done-in accordance with San Joaquin County Local Health District. Home owner or licensed agents Ordinances,' State Laws, and Rules and Regulations_ of•the' San Joaquin 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.'.' . { " r l " -- ------ owner Signed- `------- ' -- _..: - -- -----------Title--- - ------------ ----------------- (if other than owner) A. I # FOR DEPARTMENT USE ONLY APPLICATION ACCEED BY- ----------------- PT DATE '` DIVISION OF LAND NUMBER..: ----- -----------a; :. DATE --------- ------------------- : . --- ADDITIONAL COMMENTS.-------- :------------ ------ ------------------------------------------------------ -------- •-------:--- - -- --------- - := = --------------------------------- -------- ----- ------ - -- E _ - --------- - --- -- ------:'---- - --------- ` - -------------- ----------- ---------- - ---- c -'- - - -- l/t�-C�Cf .- --- -:-- b = ---- --------- --' - y.� Fina{ lns ection b �- �' a e-- 1. - - ----- - -- p Y F&5 21677 REV. 7/76 3M EH 13 24 SAN JOA IN LOCAL HEALTH DISTRICT -