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FOR OFFICE USE: ,moi FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _c r/ --------------------------------------------------------- Permit No..- 7 __/d (Complete in Triplicate) -- Date Issued--_____._._---------- --------- ___________________________________ This Permit Expires 1 Year From Date Issued t a 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 co pliance with County Ordinance No. 549 and existing Rules and Regulations: + 7 y. CENSUS .TRACT OB ADDRESS/L ATI / ------� - �-`- - t --- -- - Owner's Name ice'-------- ------------ --------------------- -------------------------- Phone ; Address e { Pr 5l."`- ¢ zip --------------------- --City--- Tr ------ T . - _ p� - City Contractor's Nam e.-__._ L. _ ----------- ` - .- -[. License #_ -._ . _ Phone°-- ._bx:_ - �- -�- - Installation will lserve: Residence ❑t Apartment House ❑ Commercial 24 Trailer CourtiEll p _ Motel ❑ Other------- ------------- = --- ... Nu bet of living units:- ''Number of bedrooms`_ T^Garbage Grinder"'Lot.Size.« --------------- Water Supply: Public System and name - -------------------------------- - ----------------------------------- -------- -.-- - --Private ®, ElClay ❑ ' Peat ❑ Sandy Loam ❑]- ClaylLoam ❑ Character of soil�to a depth o ❑ Silt f 3 feet: Sand : Hardpan ❑. Adobe Fill Material-------------If yes, type---=--------.-------- ---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.must be paced ori reverse side.) NEW INSTALLATION:— (No septic tahk or seepage pit permitted if public sewer is available withinJ200 feet,) PACKAGE TREATMENT -[.] SEPTIC TANK " [ ]Z0( Size - -- Liquid Depth --------------------------- Capacity--- ------=------ -y----Capacity-- ._Type ______ ._<_.__ :,Matarial QNB- No, Compartments---- Distance to nearest: Well-------- ---_--------- ------Foundation..-_ _. �1 -Prop. Line LEACHING LINE [ ] No. of Lines--- - /---------------Len.gth of each Iin _____. � _____.Ttl' Le gh. 0--_-_------------------- -- T, $ + rd D' Box__ _ _Type Filter Material;___ — _.____.Depth Filter Material.__- 1 _�__�_______._------------------__ ----- --- or � _ � 3 � .. l I Distance to ne rest: Well______: _Faundat� n____._______ ________________.Property Line.-..-______._7__ .- ' r: f SEEPAGE PIT ji] Depth--. --_ Diameter-.3--___-__Number____ ________________________ } !Rock Filled Yes No ❑ Water Table.Depth. ':�Q r ------- ---- - --- Rock 'Size_-----------Z = 2----------- --• r r + ! . i Distarice to nearest: Well__..___.__L�_ ___________________________Foundation__.__._ - 0 Prop. Line------- -__ -_______-____ REPAIR/ADDITION (Prey:Sanitation Permit#--=-=--- ------------------------------ --- ------Date--------------.-- __..-_:--__- ) __ . Septic Tank (Specify Requirements)________ _____ ______________________________________ ------- .l---------------------- l Disposal Field (Specify.Reeaqu.i.r_ements)-.=_ y � •e ------=- --------------------------------------------- --------------------------------------- ----------------------'------------------------------ ------------------ --------------------------- -----=------------------ - ------------------ ,, :_ - ----------: " (Draw existing and required addi ion 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 Sari Joaquin Local Health District. Home owner or licensed agents signature certifies the following: : t t "I certify-that iw the performance of I.fhe work for which this permit is issued, I shall not employ any person in such manner as to become subj o_.Workman' Compensation. laws of California. _ Signed 11`'-- ----- Owner By-------------- ..............--- ---- --- -`.------=------=-------------:------ --------- ------- ----.Title---- -------------------------------------- -------- ------ --=- --- (if other than"owner) ,. r FO DEPARTMENT USE ONLY APPLICATION ACCENTED-BY. ------ — AT-E= t - - 7 DIVISION OF LAND------------------------- NUMBER---------- - D E------------ .:.:; 4 -----�_rC "/ ------ -ADDITIONAL COMMENTS __�-- ---- -- -----------------------------------=- _ - -----------.-------------.--------------- ----------- ----- C ----------------------------------------------- ------ ---- - - - ------ - ------------- -------------- Final Ins ection•b ''' ` _, = _--==-- -------------------Date.-� EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M I