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I 0I FOR OFFICE USE: ' OFF(CE USE: ' APPLICATION FOR SANITATION PERMIT 7i-Xfy Permit No----------------- ----- ----------------- -------- --------- ---------- --------- (Complete in Triplicate) Date Issued This-.Permit Expires 1 Year From Date Issued ------------------------------- I Health Application is hereby made to the San Joaquin Loco ce No. 549 and existing Rules and Regulations: work herein described. This application is made in compliance with County Ord+Wan V -- ------- ------ CENSUS TRACT.. ' JOB ADDRESS/LOCATION. -- ------ ------------- --_Phone._�� Name --- --r� ---------------------- Owner's +�-- -472-------------- -------------------------,/ -.: ----- Address. -��- � = � ', #Y - -- .. ZI p ' ; '.License #--- -�11 Phone." - Contractor's Name--- ----------------- 4V Apartment will,serve: Residence Apartment House.[] Commercial ❑ Trailer Court ❑ Motel ❑ Other---`---------------- .- _ ----- . p� t _ �.------Garba Number of living units: Number of bedrooms- -- ge.Grinde�r-_-"�. ---"?Lot ize----------------=----- ---------------------------- ---- I �> Water Supply: Public System and name_.-„------_--- = F- Private /] . fl, Character of soil to a depth of 3 feet: ' Sand 0 .Silt❑'Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ / I i Hardpan ❑ Adobe %� Fi'11 Material"- -------If yes, type--------------------------- - A (Plot plan, showing size of lot, location'of system in relation to wells, buildings, etc. must be placed on reverse side.) Nose tic tank or seepage pit permitted if public ewer-is available within 200 feet,) NEW INSTALLATION. f( p T PACKAGE TREATMENT' [ ] SEPTIC TANK [ Size--------------a--- `---------`---I-r =-------------=':Liquid Depth.---------------- ----- i/s .i� Capacity D. p ! al --'-No. Compartments--- i • p *'ted / a Compartments---- pe.- ___------Mater) ,. Distance to nearest: Well..---------I ___-- -"- o�daon-.- -- ---- - Prop. Line Total Len th.._2..7d�- ---------------'-- LEACHING LINE [,1 No. of Lines.-. ---------------". --.Length of each ling. __ -,--------:--------- �1 g ' ---------------------------------------- ------------------- ----- # 'D' Box.-/.------Type Filter Material-- -- Depth Filter Mater+al__ d--------- ----- ---- r ------ Distanceto nearest: Well----.------------------------Fo ncdation r'=------------ -.Property Line.------------------- I elf R F N SEEPAGE PIT L 1,- Depth---- t------ D.iameter-=-- a -��Number-------------------- -------- ----------------------------- ------ Yes s o I -------------- Water Table Depth)' --------- ----------:--------------:--.Rock Size - = is t -- I k : Distance`to-nearest-Wei1-----------------------? Foundation ,:". Prop. Line" `!' --=--,Date------------- - --------------- RE --------- ---) REPAIR/ADDITION(Prey. Sanitation Permit#-_-------------- - k Septic Tank (Specify Regdirements - ..----- ------------------------------------------ IIIr ------- ------------------------- Septic ----------------- -: El y ------------------------- ------- Disposal Field (Specify Requirements)------------------------ ------- ��``""-"----------. ' - ----- ----------- f ----------- ---- �. . t -------------- ------= ---------- -- ---=------------------------------ --------------------------- ------------ ------------- -and existing-and `required addition on reverse side) I hereby certify that I have prepared this app ical tion and that the work will be done in accordance with San Joaquin County Ordinances,. State Laws, -anc1'- es and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: f "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 C mpensation laws of California." t--- -- ---------- ---- --- -- ----0-Owner wn Signed_;-�� -- - ---- ---------- - - : Title------- - (If other than owner) FOR DEPARTMENT-USE ONLY APPLICATION ACCEPTED: DATE-- ---- ---- ----------- DIVISION OF LAND NUMBER.:-----;------ ------ - --------- - DATE--- --------------- ---- ------- ADDITIONALCOMMENTS --- =------------------------------- --------- ------------------------------------ --- ------------ ------------=------------------------------------------------------------------------- ---- - - - -------------- ------------------------ - - = ------------- � �--- =--1'f - ------- ----Rate------ - --.- �`- Final Inspection by:-. p "------- "r`� F&S 21677 REV, 7/76 3M EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT