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i FOR OFFICE USE; FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit .-..----••-------------- --------------------------- ---- (Complete in Triplicate) ---------- Date This Permit Expires 1 Year From Date Issued pp y q p ex' Rules and d install the work herein described. A plication is hereby made to.the San Joaquin Local Health District fora permit to construct and This application ismade-in compliance with County Ordinance No. 549 and g .CENSUS TRACT------------------ ---- -- -- JOB ADDRESS/LOC ATION....---.�1----- ------ -- -- -•�""=•`.---- - ------ jr Owner's Name G�C•.dr1..t� .... ......... ........ .. ----_Phone------------- ---------- -- ---- � G zip --- ...._..Address- G. ; one------- Ph Contractor's Name.. ------------- ------ w --- r-�-- License #........... t� Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- ---- - Number of living units-----------------Number of bedrooms...:.----...Garbage Grinder... -.----.Lot Size--------------....... --------- Private ❑ f Water Supply: Public System and name... .. - •------ ---------- --------------------- z Character of soil to a depth of 3 feet: Sand Silt F1 Clay F-1 Peat El Sandy Loam El Clay Loam ❑ a 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,) I _-Liquid Depth....: ------------------ Size....__r --------------------- Capacity-. PACKAGE TREATMENT SEPTIC TANK Capacity-. .... --- Type---------------- - --Material........ ------------------No. Compartments--- •------------------------------ Distance to nearest: Well.:----- - -. -- ......Foundation---------- - -------------Prop. Line... ---------- 4 'Length of each lins.------ --Total Length ._ ................ -- LEACHING LINE [ ] No. of'Lines ---.-.- -------------- 9 Type D' Box_ . . - ....7 a Filter Material.___.. ..... .. ..Depth Filter Material..... wProperty Line.---------------•---- ------------- .. Distance to nearest: Well--------------- -------------Foundation---- ti - --- ._,.-- `• � Rock Filled Yes ❑ No ❑ SEEPAGE PIT [ ] Depth.-th.. -- ... Diameter---------------- Number Table Depth------------- k Size._.... --------------- Roc - ------ -------- 1 -.Prop. Line........ . . . ..... Distance to nearest: WeIL....._............. . '.------.....Foundation--- } -----Date--------- - ) I REPAIR/ADDITION (Prev. Sanitation Permit#-------� - ••------------ - - Septic Tank (Specify Requirements).__ -- -- I ---- ----------------- •---•--••. .... ----------- ----- Disposal Field (Specify Requirements)...................._. ..- ----------------- _.�. �. l ...------•-- ----------------- ------- ....... ............. .....................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 fallowing: in such manner as "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson to beta act to Workman's ompensotion laws of California. -77Tc.rc/u� f�� - --..Owner ---------------------- - - _.. Title----- ----- --------------------- ------------- ----- .............. (if ------- - (If other than owner) f FOR DEPARTMENT USE ONLY DATE _. .`o ...... ._. APPLICATION ACCEPTED BY------.. ... -................ ..... . DAT ---- ---- - • -- --- - DIVISION OF LAND NUMBER------------- - -------------------- -- --- ADDITIONAL COMMENTS---------------- -- -- --------- k ------------•- -------------- ------- --- .---------•-------------- Date 4/_ �.�-- -- -- --- Final-lnspe'ctian b -l '�'s ^'� .. y:................ (iJr�} Fds 21677 REV.7/76 3N EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT v✓