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I FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----'---- - ----'-----------'---- - ---'- Permit No. .-- ~- / (Complete in Triplicate) ,) .-.4 s --------------' - ' '----- ------------------ - - •-•---------------------- ------------------ ------ This Permit Expires 1 Year From Date Issued Date Issued_11-9-d.��e, ` 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: 4 JOB ADDRESS/LOCATION --- -----=' CENSUS .T ACT._.=- Owner's Name ----- - t.. _._. � ' == i�_ --------------------------- ------------------ . CIt - ZiPAddress------- -' --- ------' --------- i --- - --- - --- Contractor's Name------__ - _ ---------- ense #__-- ----- ----= ---------Phone-------------------- . : 1 Installation will-serve: Residence Apartment House.❑ � ommercial ❑ Trailer Court ❑ y t Motel '❑ 'Other-------- + Number of living units:._'.__ - Number of bedrooms_._ __:_...Garbage Grin er. - :Lot.Size............ ........ .....:... ..----- Water Supply: PubliciSystem and name-_.=--_ --. _. f ;_ - ------------- Private -------------- J. riva Character of soil to a depth of 3,feet: Sand []'Silt❑IClay n=�Peat❑- Sandy Loam-❑_ .--�Cla� Loam i M Hardpan [1� Adobe,❑--Fill Material------ yes, type----------- .........:....... �• [Plot plan, showing size of lot, location of system in relation to,wells, buildings;etc. must be places! on reverse side.] NEW INSTALLATION: 71Not ieptic tank or"seepage' pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT '[ ] -4-SEPTIC-TANK[-1 '' `' Size: =--------------- : f-:Liquid Depth.-._ I .______-..'' t' _----------'�`.----------- Capacity----- ------ `TYp? ' =:= " `---- :.Material------------------ --- -No. Compartments--- ----------- 6_ , -Distance to n.'earest:.Well _..- ..... -------------Foundation-------------- _.Prop—Line_. --------- - LEACHING LINE: [:.].....No. of Lines. :..,__.:___' _ Length of each line. = -= -- -:----..Total Length .S ' -`..f= .. .-.,.TypeDepth Filter Material----------------=- -------------------------- - I �Q' BOX--,:--- Ci - nto nearest:FWeI Well--; ------=- -..Fou d .. .. . .. ... � _.. ...r. Yk Distance ------- - ----------- - --------------- --- Pro �. . �...,.:,_. . .. at on ty Line i � er SEEPAGE PIT b } - ❑ [ ] Depth-- - Diameter_: = Number ----------- - _:. ; p Rock Filled Yes ❑ I; k Water Table Depth -----------=-------------=---------- _Roc Size-.- ----- f-- _ Distance to nearest: Well ------------------------ Foundation = = _..Prop, Line Y -` REPAIR/ADDITION (Prev. Sanitation Permit#.-', ip ----------- Septic a , Tank (Specify Requirements) ------ ----------- - --------- ---------------------------- Disposal Field (Specify Requirements)_- .. . . ....... ...R-...._ -: � __- --- _� -' --- ir - - - = ------ ----------------------------- -------------------------- - ---------------- " -------------------------------- (Draw' existing and required addition o'n reverse side) - I hereby certify that I have prepared `this application and that the-'work will be done in accordance with San Joaquin 'County C Ordinances,` State Laws; and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: s "I certify that in"the performance of the work'for which this permit is'issued, I shall not employ cny person in such manner as to become subject to-.Workman's .Compensation laws of California." i Signed----- :; -- - t -- - -------- ---- Owner BY-------- = .. Tit 4 -_.T' le----- -- (If other than-:owner] FOR-DEPARTMENT USE ONLY y [ APPLICATION ACCEPTED BY--- DIVISION OF LAND NUMBER: :... ----------- ----------- DATE ' --------------------- .. AQDITION/aL COMMENTS. --------------------.------------------- ;------'------------------------------------- -- - ----------------- --------------------------- --- j------------- --------- - - ' Finallnspection by o-------------------------------------- ---- ------- -- ------- -- - -- -=- Date.. EH 13 24 SAN JOQUIN LOCAL HEALTH DISTRICT F&5 21677 REV.'7176 3M