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FOR OFFICE USE., V FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT permit No ------------;i---------�---- - - --------------- (Complete in Triplicate) � ...� '-��-/---�- ----------------- --------------- --- �. - ; Date Issued /-i.5--/O { _________________________________________________________ :,;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 ap lication is made in co licinc with County Ordinance No. 549 and existing Rules and Regulations: 10: 10267_ `',- c110"c� OB ADDRESS/LOCATION----- ......... ------ ----------- ----0 ..-____-- ---CENSUS TRA Owner's Name �- -7t.. - ---�24�------ - —�_.Phone- I. Address -------- ---------- ------- ---City zi Contractor's Name---------- __. -- ----- - ------------------- -License #- �A �-----Phone-- ------------------------------ Installation will serve: Residence ► Apartment House.❑ Commercial ❑ Trailer Court ❑ 91 Motel [--I - Other--- ------------------------------------------ yi 1 Number of living units:---- ------Number of.bedrooms____/__Garbage Grinder------------Lot Size__. /d_ _�----------------------- Water Supply: Public System and name----------- -------------------!--- i----------------- --------------------------------------'----------------Private Character of soil to a depth of 3 feet: s Sand +Silt[-] .Clay E] Peat ❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobes❑ Fill Material-- ----- --If yes, type-------------------------------- (Plot plan, showing size of lot, locatiori of system in relation to,wells, buildings, etc, must be placed on reverse'�side.) [� NEW INSTALLATION: (No septic-tank—or—seepage ppi it permitted if public sewer i's available within 200 feet,) PACKA•CTR'EATMENT [ ] - SEPTIC TANK . /Size « � tlih amept ��----._-J � / ______________Liquid D Capacity I -�- --- ----�� - e. - ----_._-Materil - -------No. C tante to nearest. Well_ �-d - -------------------Foundation----fP.i...---- --Prop. Line. - -_-- �J r --- ---------- i i LEACHING LINENa, of Lines-..--- -----------------Length of each line..._��.-__-_---_:_.____.Total Length ....... --�d---_-------------- Ix s All D' Box_ �__T {e Filter Material-�AAC/11e_.De th FilterMaterial Property---Line__I ----------------- Yp_ p ,i Distance to nearest: Well_,_____ _�_______---Foundation--- '��'_______________________ SEEPAGE,PIT [ ] Depth---------...;—Diameter-- -------- Number= -------------- Rock Filled Yes ❑ No❑ Water Table.Depth---=------=-- ---- :-- -------Rock Size------------------------------------ � Distance to nearest: Well.-T-- ` T'--- ------------- Foundation-------- ------------------Prop, Line--------------------------- s �-. ' REPAIR/ADDITION (Prev, Sanitation Permit# ----------Re,-1----------------------- ---------- Date.-----,------------ --------------------------]' , Septic Tank (Specify Requirements)------------------------------=---------------------------------------------- ---------------------------------- ';------------------ DisposalField (Specify Requirements) --------------------- ---- -------------------------------------------- ---------------- ------ ------------------- -- ----------------- 1 ------------------------------- ------------------------------------------------------------------------- -------------------------------------- - - - ---- - - -- (Draw existing and required addition'on reverse side) F 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, Horne 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 any person in such manner as j to beco ub'ect to _Workman's Compensation laws of California." Signed- -- --�---7r -- ---------- ----------- ------:Owner ; BY--------------------------------- -- � ------------------ ..---- --------Title.......-- ---------1------ - - ------------- -------------- (If - -------(If other than 'owne. i F R 4EPARTMVNTfVSE ONL APPLICATION ACCEPTED BY--- ------ _/Lc --------- ' ' "' -----------------------DATE. _/V3- 7P--------=--- , R DIVISION OF LAND NUMBER.:-------------- _________ ____________ DATE ADDITIONAL COMMENTS------------------------------------------------------------------------------------- ----------- �---------- --- -- -- --- N11 ----- ------ ----------------- ------ --- ------------------ -----------------------.-------------------`------------------ ---------------------------i------------------------- ---- - ------- --------------------- ----------- ------------------------- -------------------------- _ i 1 Final Inspection by:-_-. -__Date--_- _ .._ � r- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT ra 27 REV. 7/76 3M J