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FOR OFFICE USE. FOR OFFICE~ USE: � APPLICATION FOR SANITATION PERMIT 9 ............................................. Permit No.... ---•. (Complete in Triplicate) --"-- ..................................... Date Issued..h--OR_31.... t ......................................................... This Permit Expires l 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: i CENSUS TRACT.---............ - ------- JOB ADDRESS/LOCATION.... .9.-�-�..L.`.-... ... Owner's Name.--- - f,rir', G� r-Zt 11 7ti --.. Phone p Address--- lJ. ... ---- ",.. City----------- -------4----_y Zip-------------- r Contractor's Name...<e� r __ t License #_ �-U-.L Phnne." ,! °�' l .... Installation will serve; Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ 'R. Motel ❑ Other---------------- - - --------------------- - Number of living units:... -umber of bedrooms..-.- -Garbage Grinder............Lot Size... -. '" ....... . _-.Private ] Water Supply: Public System and nome---------_- � --------- i 1 Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loam ❑ -- Hard an-g ,_Adobe Foll :Materiat.... -If- es-t, e--- ......... •r IPlot 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 [ j SEPTIC TANK [ ] Size v ........ Li th.`�------ ----------- �x.-�---h- quid De p Material ._.. _ --.--._No. Compartments--- Ca acit Distance to nearest: Well-...__/0.a................ .........Foundation------1,eF.-.a....... ...Prop. Line_...�100!.... -...il„ LEACHING LINE . [ ] No. of Lines..- _..._....Length of each line,--44-0--------------------Total Length _1go--------------....----"•- _., Ir Ir 'D' BSW- Z...Type Filter Material...- . Depth Filter Material..../-- ----------------------------------------------------- Distan a to n ar- : ' e +�-.---.-- -- Foundation---------------- --.... Property Line..-- SEEPAGE PIT [ ] Depth 1 m4 . ___.....Number.-+ '---- --- ---------4 1 Rock Filled Yes No Water Table Depth-----.-.- ------.....Rock Size.----- ---... Distance to nearest: Well.-.- ------------------ - ------- ------Foundation...----............ Prop. Line------- ---- ..._..- REPAIR/ADDITION [Prev. Sanitation Permit#----------------- ------ ----------- -.Date--.------------------- '- -----�--} , > Septic Tan (Specify Requirements).---.-.------------------- --------------------- ---- ------- - - -------•- ----- Disposal Field [Specify Requirements].............•-.-...-- --•----- ------------ ---------- ......................... f -------------- --- ........ ----------------- ---------- ------------- .......... ---------- --------------- ...... --- - =- - .-- (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 subject to Workman's Compensation laws of California." Signed ---- ------------------- ----Owner BY-•---- ----- Title...-- ---- .. -----.... --- ............ (If other than owner) F DEP TM NT USE ON Y YAPPLICATION ACCEPTED BY-------._ : .l�"'• --- --- ------ ------....DATE ... , DIVISION OF LAND NUMBER......... DATE ------------ ----------- --------------- -- ADDITIONAL COMMENTS................... :_..... - k � = =------ q ...---- - Final lnspe'cTion by:-- ------------- ------------------ ------ . ..._.. _.... :... / EN 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21477 REV. 7/76 3nrt