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FOR OFFICE USE: i/ APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: LDat mit No..��--�- -�1-`�--- ------------------ ----- ... ............... (Complete in Triplicate) ................................................. ` e lssued...P_.J)-_T.-?,R This Permit Expires 1 Year From Date Issued Application is hereby made to.the Son'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: 1 JOB ADDRESS/LOCATIONI .... --- - - -- ------ ....................CENSUS TRACT:----------------- . _.. - f .. 7 _ 43 Phone... ... . Owner's Name. � . - "'�--- .. ........ ....... JQ. �..-.. ----- ------------ City_...... - Zip---=------ ---- -- ---- Address .. ..... .......... .. ILi .-..-. Contractor's Name- ------ .... ........ cense #_ Phone. :.. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other..... ------ - -------------------------- Number of living units:.--------_-----Number of bedrooms..-..... - Garbage Grinder------------Lot Size-------..._........-. ... I I Private ❑ Water Supply: Public System and name.... .-------------------------------------- - Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ I Adobe ❑ Fill Material-- .... ....If yes, type--- -_-------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) . a avgilable within 200 fe et, NEW INSTALLATION: (Nosepticrseepage pit if public sewer ,s I ---------Liquid Dep th .------------- ---------- PACKAGE SEPTIC TANKSize ' � MNo. Compartments ----_--------- Capacity.. _ - ... ...Type.-.-------- ... Material ----- Distance to nearest: Well-------------------- --- ..... Foundation...---- ...._.Prop. Line.................... Total Length .. --------- -------- --- --- LEACHING LINE [ ] No, of Lines- ------------------- ------Length of each line g 'D' Box..... Type Filter Material- -- .Depth Filter Material-- ---- --- - ----- Distance ....Property Line...--- ------. Distance to nearest: Well.........:........ ........ Foundation--------------------- P �. ` Rock Filled Yes ❑ No ElSEEPAGE PIT { j Depth. Diameter------------- Number--- ---------- =..... RockSize--------- -------- - ------ ---------- Water Table'Depth.---•------------- - -------------- ---- ;:........ •....... I ] -Foundation Prop. Line Distance to nearest: Well------------- ----_ ^- REPAIR/ADDITION (Prev. Sanitation .l Permit#. - Dated. :- - - } Septic Tank (Specify Requirements)_... �t -' ----------- - -------------- Disposal ---Disposal Field (Specify Requirements)............... • t ----------- --- :........ ............... ------- ------------ I (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, 1 .shall not employ any person in such manner as to becom ub'e t to orkma 's Compensation laws of California." Signed---- / ------ -u'' ... ---•---------- Owner ......Title ------------ (lf other than owner). . F, R DEARTMENT USE ON APPLICATION ACCEPTED BY--------- ' .�--- - C- - --" -----------... -DATE ......... ... .�.� -7�-- ------ DIVISION OF LAND NUMBER --------- ----------------------- ---- ----------- ;; DATE ... --- ------------------ ADDITIONAL COMMENTS-------------- ..... . •------------------------ ------- ---- -------- ------------ - - ---....---..---_ ... -- --- - - ------------- -•----•----- -------•-----• -------- ------ ------ - ---------------- ------•- Date /! Final Inspecilon b EH 13 24 SAN JOAQUIN LOCALaEHISTRICT F&S 21677 REV. 7/76