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FOR OFFICE USE: J/J FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. "'-""'-•-I........... ......... ........ This Permit Expires 1 Year From date Issued Date Issued..f:r'I"_Jf Application is hereby,made to the San Joaquin Local Health Ypistrict for a permit to construct and,,install the work herein described, r This application is made in compliance with County•Ordinance No, 549 and existing Rules and Regulations: v I JOB ADDRESS/LOCATION...-.-�_ •---- --- -_.CENSUS TRACT. j Owner's Name.___. . Phone.............. ---------- --- ---- Address..---...-.- 1 Cit ---...- -- ----- .. Contractor's Name..... �� License # �- 3-I. —1. .Phone--- ---- Installation will serve: Residence&Apartment House"❑ Commercial ❑ Trailer Courtl ❑ Other-- --------------------- ----- ----- Number of living units:.---_.._. Number of bedrooms--_.. �• - Garbage Grinder---•--------Lot Size------'I ........ :....... ....:...•-............. .. t Water Supply: Public System and name'_.... ............ .. .....Private I Character of soil to a depth of 3 feet: Sand ❑--Silt-E]--Clay-[—Peat©---•-,Sandy Loam ❑ Clay Loa Hard pan ❑ Adobe ❑ Fill Material.. .... . _ If yes, type-------------_-_..._.-_. (Plot plan, showing size of lot, location of system in relation to'wells,'`.buildings,ketc. must be placed on reverse side.) NEW INSTALLATION: (No septic torikq or seepage pit permitted if public sewer is available within 200 feet,] F PACKAGE TREATMENT [ ] SEPTIC TANK [1] Size...l.-,�.._ ----- - ---------.-.L.-.Liquid Depth.- --------- -- ---. IvJ Capacity`..t-.r.-0.__Type____4_ _.._ .Material.- _ - . . ___.._.._No. Compartments Distance to nearest: Well-_._--- Foundation......... .... .. ...Prop, Line-------.-_.............. ._ LEACHING LINE [ ] No. of Lines ..... _._ ------------- Length of each fine____ . Total Length .. 'D' Box.....' .....T !J ype Fil#er.Mater-ial..:-/` ._-- -Depth Filter Material_..._.-- --- - ----------------------------------------- - Distance to nearest: Well--- Foundation__._-____.__________________ Property Line..__ SEI PAGE PIT [ ] Depth--- .. _-_.Diameter_:`:__ Number---.._.___ ------------------- Rock Filled Yes No Water Table Depth----------------- •7----------- --- -- ---- -------------Rock Size-- .. . Distance to nearest: Well.......... ._,D...............Foundation .--.--.-.................Prop. Line-.--.-. . REPAIR/ADDITION (Prev. Sanitation Permit#-_-.___------- --- _6........ ...............Date-_____-------. ] Septic Tank (Specify Requirements]._.__ f.¢ t t 4 ; Disposal Field (SpecifyRequirements)................. .... ..... _ ` - k ..................... R ...............I------- TTT.....+++.i{illl!!!! (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 person in such manner as to become subject to Workman's Cbmpensation laws of California." I Signed.-..----- - - -- -------- .. .... ... ........... ... nes BY-•----•... ... .... ... ---- itle.. r (I at r t a ow ed F DEPA06MENT USE QNLY APPLICATION�LAN�DNUMBER D BY-------- _yam....... :....:.. DATE ......... L 7 ... ---- Q DIVISION OF ._.._.._.... .......................-------------- ----.DATE------------ ADDITIONAL COMMENTS--------------- - �! �. . .. ..... ....V __ -------------- -------------------- --------- - ---- =:::::::::::::::::::::::::::::::: Final Inspection b - y y Date------------ ---- ------- ..... EH 13 24 SAN JOAQ61N LOCAL H LTH DISTRICT F&S 21677 REV. 7/76 3M