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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------ (Complete in Triplicate) Permit o..-....__-___........_ % Date Issued........... ---------------•-••-------------------.------------------ # This Permit Expires 1 Yecir From Date Issued I. Application is hereby made to.the San-Joaquin Local Health District for a permit to construct}and install the work herein described. This application�OCATIC;N omplionce with County Ordinance No. 549 and existing Rules and Regulations: JOB ADbRESS -_�.. _ -6 .___._--CENSUS TRACT.._.............. .. . Owner's Name.... ..... (.i. iL .. Phone........................ ........... f Address--------- Crrr .................. .-.. ........ .... _....... City------------------- _-- -- -- --... Zip_..: �i //�� Contractor's Name--- .. -- ------- - -- ------.-.......License #.. l/_ / Phone..- - w-..- °T� '9 plc - 7 Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other........ - ---------------------- Number of living units:--------I------Number of bedrooms.... ....Garbage Grinder............Lot Size.-----: Water Supply: Public System and name-- ----------------------- --------------------- ------- ------------- -------------=-- --.---- - -- - - •-------Private � t Character of soil to a depth of.3 feet: Sande Silt .r C!a y`�"`5� _ — 6 p ❑ ❑� y ❑ /Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material.. .... ....If yes, type----------------- (Plot plan, showing size of lot, location of system in relation to'wells,'buildirigs, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size . ///� �]�� Ir�.: Liquep .__ - . �} �� ff._�--f- id Depth ...- ------- - Capacity..I4I0..0--1.-Type --_J.............Material... ? --..No. Compartments-----..--- O Distance to nearest:.)Nell------ - �i .--_�----- ----------Founciation_..-- Prop. Line............... .---.-.---..� LEACHING LINE [ ] No. of Lines t g f each line....------------- ------Total Length 1 s � ..................... D' Box....J. ...!.Type Filter Material..—I :---.Depth Filter Material...----7-"------- ---------------------------------- -- ---- _ -�_.., Distance-to-nearest:-Well=-r_'_..1.: __....Propertyoundation----------------------- Line...-............----:,............. SEEPAGE PIT [ ] Depth__�.y --- -Diameter__ ......Number..... ____________________ Rock Filled Yes Na E]e._ Water Table Depth--------- --------- ----------- -.Rock Size----- --- Distance to nearest: Well---------------- ................Foundation--------..................Prop. Line............ --------. REPAIR/ADDITION {Prey. Sanitation Permit#------- -----------' ' ........Date................. ..----_----.--..-----( Septic Tank [Specify Requirementsl... ...................... --------- ........_ . ...-- Disposal Field (Specify Requirements)----------- ------ - -------------------------- ----.-.------------ ------------•------- ---------- ---- -------------------------------- ----- .......... .... ..... - -- ------------- 3 � - - ..... . ...................... ._--------_------.-..------.-.- (Draw existing and required addition on reverse side) n 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 Son.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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed------ -=---- ----------------- Owner ByTitle.----- ------- --------------------------- ------- . t (I other than owner) FOR EPART NT USE ONLY .. APPLICATION ACCEPTED BY.......... . .rZ :- - • - --- - -- -- ---- ( .. ..... .DATE .--- ..:. V DIVISION OF LAND NUMBER ............. ---. ... - DATE ADDITIONAL COMMENTS. ------ --------: ..._......... ..:...,.. --•- --- - -- ------------------- - • ................ ...... ----- - ----------- - ----- --....---- Date...Final Inspection b EH 13 24 DISTRICT A F&S 21677 REV. 7/76 3M {