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FOR OFFICE USE; FOR OFFICE USE: S•° _ APPLICATION FOR SANITATION PERMIT, i (Complete in Triplicate) Permit No...._.. .. .. ... --- Date Issued./�-3a-7� . ......... 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/LOCAT N -40/01 a. ,- fpeC. le yl�J. ..- '-.- -- CENSUS TRACT...---- ............. p Owner's Name ---.... ... . ---... Phone,.k-SJ✓.'= �_ . Address---.---- . . �.e- . _.. .....7. - -- -------.. City Zip @,� Y+ ... .._..D7�C�............... License # .7.-3. Phone _(6A_ al�_- Contractor's Name...... 7 - Installa#ion will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other......... - Number of living units:-..-.-----------Number of bedrooms........; Garbage Grinder= Loi Size_ . . .......... - Water Supply: Public System and name ................ .:.... . ..... . ----- ...................... . ------------------Private Character of soil to a depth of 3.feet: Sand ❑ Silt❑ Clay ❑ Peat Sandy Loam I]. Clay Loam ❑ Hardpan ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT M t l r [ J SEPTIC TANK j'%+ Size._.._ �i -9---------------------------------_ -Liquid Depth��'-- -<----..------- Capocity- ` - Yp� !L i_� - -T e---�--"-. ......:..Material---�,.��{.4...r._.._No. Compartments....---. ------- ---....._. Distance to nearest: Well------- ..........................Foundation-..��-- . ----.. ....- Prop. Line_._.5.---.' ......... LEACHING r r NG LINE Na, of Lines .�._.,.M ..............Len Length of each lino... Total Length .. .lam__..____._. _ .. ° i Q' Box----✓.Type Filter Material... •......Depth Filter Material. --------------------------------------- - - Distanceto nearest:.Well--/.M---1-- _-....Foundation... -I—-..-------Property Line....S------------- --------------- SI EPAGE PIT Depth _ Diameter......-.-.-- .Number---.,;,... Rock Filled Yes No e K / +r Water Table Depth ------ ----- --- ------ /---- ....- .Rock Sizer. .,.' . r�...tri -- _L y Distance to nedrest: Well.--------li __- --_-------.Foundation---------�.... -- - ..Prop. Line.._. ...--------------- REPAIR/ADDITION (Prev. Sanitation Permit#----------------- ------------- ..-- -......--.Date----------..--->------------ - .-- I 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 th 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." ' . ; ....... -- - .OwnerSigned----- --- -- ------------- ...... ...............Title. . .....-- ----- .............. .BY - - -- - --- --- ------- .... (If other than,owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.... -- `------- ----------------- ----- ..... -------.. --• ---- ---------- _DATE .....k1__. �.�. DIVISION OF LAND NUMBER - -----------DATE----- ------- - ------ --- -------------- - - ADDITIONALCOMMENTS-------------- - - -- - -----:-------------------- - ----_-----------_.......•------------------------- ------------------ ------------------ __ -- -- - - I ................ - ---- ......... : ------,-- v--;n . .. -------------------------- ------- -- Final Inspection by:- SM. --------- --- --- ----- -----------..Date.----- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 7/76jM 1