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-- FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT \ it No------ - ---------------------- ----- ------ ..[Complete in Triplicate) Perm ------------------------I------------------------------ - k �---. , t `� �, 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 Ordinana No. 549 and existing Rules and„Regulations: JOB ADDRESS/LOC ION,- -CX-- /� r ” ---------------------- CENSUS TRACT--- _-------- ---------------- Owner's Name.---- - --- ----- ....... ----------- ------ Phone---- -------------------------------- VAddress------- --- City Zip r� �; t Contractor's Name------- ^-. 1 ' ------------------------------License #.-4-,7-f-!;3 .-Phone---------- Installation will serve: Residence Apartment House.❑ Commercial E] Trailer Court E] Motel ❑ Other_______________ ~Number of living units:____----___Number of bedrooms -_Garbage Grinder__.__.____Lot Size___/.._�a_ -------------_______ ,Water Supply: Public System and name----------------- ---- ---- - -- ----- -------------------------------------------- -----------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobex 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r PACKAGE TREATMENT [ ] SEPTIC TANK Size - _f s__fXf---------------------------Liquid Depth.----,;/__________._____, ew CapocityjaO,Q-------TypePW-e�Material--0-�)4y --------No. Compartments-----------�--------- ---- r vr- f Distance to nearest: Well-------�____________----------____________Foundation.___.1________i___.___Prop. Line_-�___. -.--__- _- ��`V. r LEACHING LINE � No. of Lines ________________Length of each line.__-_._ Q___ Q.Total Length.__..f 'D' Box---/-----Type Filter Materialr,57e_C/-_Depth Filter Material_______ ._ __ _____.___ 11 Distance to nearest: Well----c -.__._____._Foundation__�d___-____-___.__Property Line_-�.---J f' ---------. SEEPAGE PIT Depth_.�_S__1_.Diameter----� __----Number--------_�_________________ yr `Rock Filled Yes ' No - y L.. - Water Table Depth-----------96- ---------------------------------Rock Size--->�--X-6------------------------------ r "'Distance to nearest: Well---_ 1,196�-----------------------Foundation.__ _Q_-_.____.___.Prop, Line_S-----________._____- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------_ ----------------------Date-----------------_---------------------------- Septic -_______.__ .___Septic Tank (Specify Requirements)-=----_-------------------------------------------------------------------------------------------- --------------------------------- Disposal Field (Specify Requirements)--------- ---- ------ -------------------- ---------------------- ---------------------------------------- ------- ------------ ------------------------------------------------------------------------------------------------ -------------------------------- (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, I shall not employ any person in such manner as to become subj t Workman's (CWrtpensatir laws of California." 4.w Signed �, /' `-� ---- ----- Owner ---- - Title // ------------------------------ ---------- r an L % � (If oth/ an owner) OR D P MENT SE ONLY/ APPLICATION ACCEPTED BY---- ---- --- - -------- -------- -------DATE DIVISIONOF LAND NUMBER--------- ----------------------------------- -------- -------------------------------------------- ----DATE.--- ----- --- ---- ------------------------- - ADDITIONALCOMMENTS--- ---------- ------------------- -------------------------- -------- --------------------------- -------------------------------. --------I------------ ------------------------------------------------- ------------------- ------------------------------------------------------------- ----------- -------- -------------------------------------------------------- - - - - - JI--- --------- �j Final Inspection by �`� �J - Date-- `-t__�--- ---- ------------------------ EH 13 24 boAfiJOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M