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►x � FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------------- - (Complete in Triplicate] Permit No.7.g-r-_J b t Date Issued4-1-?g.-- ------------------- ---------- ----------------- --_. 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 ins.t=aCl l°T work herein described. This application is made in compliance with County Ordi nce No. 549 and existing Rules and Regtiio s;' JOB ADDRESS/LOCATIO ��-- - -- CENSUS T _ A_ -_-_____--- -----.� -- ------------------ Owner's Name.. Ph Address------ ----..f//�� -- - -- ------ ------- - ------ Cit ----Zi -- - - Contractor's Name. �[ . --License #-.3Z?_Z1a�--Phone------ --- ----------------------- Installation will serve: Residence Apartment House ❑ Commercia Trailer Court ❑ Motel ❑ Other-..---- - ---.. _ -__ Number of living units:----L----------Number of bedrooms...-.-----Garbage Grinder------------Lot Size----..- Water Supply: Public System and name---------------- - -------------- ---------------------------------------------------------------------- -----------------------Private. Character of soil to a depth of 3 fee�t,f: Sand ❑ Silt [-] Clay [-] Peat F] Sandy Loam E] Clay Loam ❑ Hardpan LrJ Adobe ❑ Fill Material-- --------- yes, type-------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep ge pit permitted//ifpublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [� Size__Y1�_-�,1-_�-/-__. CQ ---- ------ Liquid Depth T Capacity_.,/, .?O�l-----Type-- Material--- _ .--No. Compartments-..-;?--------------------------- / Distance to nearest: Well.-.---.- a _------ ----Foundation__---- f��-_ Prop. Line-----�-.-----___ LEACHING LINE [�]/ No. of Lines.--------.-2--- Length of each line...---_Y--- g � �" Total Len th ----------- - 'D' Box----`_-.-Type Filter Material-.--- ' --------Depth Filter Material----------f_9 �'-----------------------------------------q 'yr Distance to nearest: Well---------- / __-Foundation--_-- may ____ --Property Line-_.. ------- --------- ` SEEPAGE PIT [411,11 Depth_2-•-44Diameter-------3.3-.--.Number--------------- ?_-.---- -- Rock Filled Yes E, No El Water Table Depth---------------ler- ------------Rock Size._. . -- .. -- ------------------- Qistance to nearest: Well__- le��-------------Foundation------- _ Prop, Line---- REPAIR/ADDITION (Prev. Sanitation Permit#-----....--_--------------------------------------Date.---..._-_._._._.___.___.___-_____-------_.._) SepticTank (Specify Requirements)-------------------------- ------------------------------------------------------------------------------------ I-- -------------------- ------ DisposalField (Specify Requirements)--------------- ------ ---------------------------------------------------------------------------------------------------------------- -------------- ------------I---------------------------------- -------------------------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 C*Onn 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 Compensation laws of California." Signed---------- ------------------------- ----- --------- Owner BY �/.1 . Tifile ---------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ------------- ------------------------ -----DATE. DIVISION OF LAND NUMBER. ------------------------------------------------DATE ---------------------------- ADDITIONAL COMMENTS---------- ---------- ------------------------------------- ------------------------- ------------ -------------------- ---------------------------------------------------------------------------------------- -------------------------------------------------- ---------------- ---- --- ------------------- ----- - ----- Final Insp ---------------- ----------7 -- Date--- ection by:--- -- ---- --- -------- -------------------- --------------------- EH 13 24 SAN JOAQUIN LOCA HEALTH DISTRICT F&5 21677,REV. 7176 3M