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i FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � --------------------------------------------------------- ldr,,-" (Complete in Triplicate) Permit No----------------------- ----------------------------------------------------- - - `� Date Issued.------�---�------ ' ------------------------------------------------------ -- 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO - r!. ='"'_- d�' C��L `-------------------------CENSUS TRACT--------------------- ---- - - � ------ ------ Owner's Name. ---- � -------------------------- --- ------- -----------------Phone-- ---------------------- = � 9�! Address lJ� .. ��ra4-------- City r Zip J-' 7 Contractor's Name. -----------------•----------------------------- License Installation-will,serve: �esidence Wj�Apartment House:❑ Commerc a ❑� Trailer Court ❑ k < >. - - - Motel ❑ Other`-------------- s Number of living units-----------------Number of bedrooms-�'�-Garbage Grinder------------- Size------------------------- t _. _._-.- Water Supply: Public System and name-----------------------4-------R----------='---- : ------- ------------------------i----------------Private Character of soil to a depth of 3 feet: ' Sand []' `Silt❑ Clay ❑]' Peat❑ Sandy Loam ❑ Clay Loam ❑ € Hardpan ❑ Adobe% .;F,ill Material= p:___---If yes, type------------------------------- (Plot plan, showing size of lot, location of system i"n relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION:-,,�.. (Nod septic tank or' seepage pit permitted if public sewer is available within 200 feet,) PACKAGE - Ca acit DL�,P ! � ,Size�---=-----------------------------------------------------Liquid Depth.-- ------------------- - A f TANK !b pe`" Material--------------------------No. Compartments-- -r�----=------------- --- 4 t ` f A }Distance.to nearest: We11_ d .;.._-=- --------------------Foundation.-. --------------Prop.. Line__4-Q-------------'k LEACHING LINE of Lines. ' Length of each 11nB.--. R �---------------------Total Len th ' 8 ;D' Box.J-------Type Filter Material_ pie, r____-Depth Filter Material___, - t 7 Distance to nearest: Well-----------------------------Foundation----------------------- ---Property Line---------------------------- SEEPAGE PIT [ ] Depth----------------Dia`rrieter-_------ Number------------------ Rock Filled Yes ❑ No .,Water Table'Depth--------------------------------------------------------- Rock Size-------=------=-----------------=--=------------ t Distanceao nearest: Well---------- ---- ----------------------------Foundation--------------------------Prop. Line___.--.___-___:---.-- -_. - REPAIR/ADDITION [Prev. Sanitation Permit#---------------------------------------------------Date--------------------------------------------- ------------------- , SepticTank (Specify Requirements)----------- ------------- ---:---------------- ------------------------------'----------------------------- -- ----------'--------------------------------- r 1 Disposal Field (Specify Requirements)-------.............—_----_—=� -�--�--------- '-----=------------=------=------------------------------------------------------ --------------------------------.------- ----------------------------------------------------------------------------------------------------------------------------------------'--------------------------------- _ : e ° [Draw existing and required addition on reverse side) i 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: "1 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_, mpensation laws of California." Signed--- ------Owner B C1 I ---------- ------------------------------ -Title - Y ---------- (If other than owner) { t DEPA MENT USE ONLY APPLICATION ACCEPTED- BY----- / -------------- -------DATE - DIVISION OF LAND NUMBER:-- --- ------- ---------------------------------------------- --------------:-------------------_----DATE.----- ---------- -=- j ADDITIONALCOMMENTS-..------------------------------------------------------------------------------------------------------------ ----------------------------------------------------- i + ------------------------------------------ ------ ------------ ------------- --------------------------- ---- ---- - ---- Final Inspection by:----------- Date...----�- ----�� - - - ------- --------- . -- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M