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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..... (Complete in Triplicate) Permit ------------------- ------ ............ Date Issued_ : ?,9 ` ----- - This Permit Expires 1 Year From Date Issued F - 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: ty w. 3 JOB ADDRESS/LOCATION. ..... .. .. ?.r.. +N CENSUS TRACT.................. E Owner's Name..-. FTI- - ........ Phone_.. --f.._�. -�--------------- Address-------- ------- Citi. . -. y. .. --- zip----- -._ Contractor's Name.......- I - r�. -- --- - a� �a] License #... '`�W � y .Phone___-�6 `-_-- ...-.._.... _........ ....._ .- O Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ - Motel ❑ Other--------- ------ ............... Number of living:units:.. Number of bedrooms.._-. f - Garbage Grindar-- 10-Q_.Lot Size - - ---- - -- -------- ---- - Water Supply: Public System and name............... p { --------- ------ -------------------- - ----- ---- ------------------------------------- -Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material.--.__.-_._.I# yes, type-_.......................... .. (Plot plan,,showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) x r NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size................... ....._-_.-._.-... ... .... .._Liquid Depth........................... F Capacity........ Type----- .................Material...... ...-.-----------. No. Compartments................................... Distance to nearest: Well..................-___--------.-.___...... Foundation ...... .... _ -- .....Prop. Line.............. ._. ........ LEACHING LINE [ ] No. of Lines..... ... .......Length of each fine...---- ---- -.-........."Total Length ---------------------_------- ---- - -. 'D' Bog..... -.-- Type Filter Material Depth Filter Material- ---------------------------------------- -- Distance to nearest: Well........... ... ._ -.Foundation. ..................... . _ Property Line--_--- --- .._-_______-_ ...-.. SEEPAGE PIT . [ ] Depth............. :.Diameter........------------Number.._.......__.-......-_____...__ Rock Filled Yes C] No ❑ f , # Water Table •Depth - . ._.....-- ---- :--- -.Rock Size -------- ------ --- ------------------- Distance to earest: Well--------------- ---------�-_-__;_-.----_..Foundation........-... .. ._---.....Prop. Line...... .. t REPAIR/ADDITION (Prev. Sdnitation'Perm it#----------------------------------------------- ---.Date.-_-......__-...-.-......._-_.---_-______-_---] !.Septic Tank (Specify Requirements).1.......... yltza.4�-- --� ------------------------- --- - - ----- ----------------:.......................... ..-. Disposal Field (Specify Requiremen'#s).._..._ ._ ......_..:- --------- ------- ------------ s ----------- -------- --------€ ------------------------------------------------ - - - ----- -- Draw existing and required addition on reverse side) r 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 Aules/and kegulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following "I certify that in the performance cEf 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 ..... -� ----- + (I other than owner[ i F R D ARTM'EN USE LY i ov APPLICATION ACCEPTED BY---.....--- ` - -- - - ---�------- • ------ ---------- DATE --------.. .......77 l DIVISION OF LAND NUMBER.._...__ _ � ...._.. -. DATE. - -------------------- ADDITIONAL COMMENTS ._ ------------------ ----- -----. -- -------------------------- ------ ------------- -- ------------ .......................... ............... ---- -------- - -••-------------------------------------------------------•-- _._... i' ,�.. -----•-- ......................... ----------------- ------------ ------ ---__---------- ------ - ................................... -- ----- • ---- ------ ------------------------------Date.---------- - -- --- f. Final Inspection b ..-_.... -------------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT taas 2W,7 Rev, 7176 3M