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1 FOR OFFICE USE: FOR OFFICE USE: ` APPLICATION FOR SANITATION PERMIT - -- -------------------- Permit No._.-/7f:.y (Complete in Triplicate] ------ --------------------------------- --------------- ------ Date Issued--- ---------------- �` �-�� 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/LOCATIO�N.�. "4--�Ul ---------------- ..... --------------------------CENSUS TRACT.---------- ----- Owner's Name--------------'(/..1i,,l``�(--- --- Phone �� Address �� - ,v- City- - -•-------- Zip- --- Contractor's Name. - S.--- License # Phone-.`s��"`G"D_' .. Installation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other --------------------------------------- �---�- --- Number of living units:..../--.-....-_Number of bedrooms____)�Garboge Grinder------------ Size_-.-._s (,X -(r--------------------------------- Water Supply: Public System end name = ----------------------- ------------------------ ------------- -----------------------------------Private ❑ Character of soil to a depth of 3 feet: `Sand'❑ Silt❑ Clay ❑T Peat ❑ Sandy Loam K 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 [ ] SEPTIC TANK [ ] Size_____________ ..-----------..._'Liquid Depth._________.___--.--.......Q Capacity---------------------TYPe--=----- Material------ --------- ------ --No. Compartments--- --- --------------------------- Distance to nearest: Well--------- -------------4--------------------Foundation ---------Prop. Line--------------------------_ LEACHING LINE [ ] No. of Lines....................._.___.Length of each line------------------------------Total Length .-_.----------- 'D' Box------------Type Filter Material----_----___--------Depth fifter Material__^'----- -�--___. T-_._`-_.....-..........._-___________. Distance to nearest: Well-------------- -----------Foundation____.._.__________________-Property Line.----- SEEPAGE PIT [ ) Depth----_-----_-----Diameter--------_----- ----Number-------------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth--------------------------------------------------------.Rock Size Distance to nearest: Well...... --- --------------------.----------_Foundation--------------------------Prop. Line-------------..._ REPAIR/ADDITION (Prey.-Sanitation Permit#----------- -------- ------Date---------------------------------------------) , ' SepticTank (Specify Requirements)------------------------- ----------------------------------------------------------------------------------------- ,t L"'= ---------- ��,, nn � lr Disposal Field (Specify Requirements).----------CLQ- --- ------- —-------- - - ---------- - ---- ---------- ' ((�� t� --------- C----- --- (Draw existing and required addition on reverse si 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--------- --------- - t......-z-B- 7A-------- ---- - -----------------Owner By-------------- ------- -- --- ---`---- Title-- --......---- -------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.......... --------------- -------- ----------- ------------------ ------DATE --- 3 7�-------------------- DIVISIONOF LAND NUMBER------------------ ----------------------------- ---- -------------------------------------------------DATE.----------------------------------------------- ADDITIONAL COMMENTS - ----------------------•-------------------------------------------------------- -------------- ---------------------- Final Inspection by:--------------------- - -- Date- ----� --- -------------- - ----- EH 13 24 SAN JOA IN LOCAL HEALTH DISTRICT F&s 21 7 V. 7/76 3M