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FOR OFFICE USE: , 2- -Zn / APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: - ------------------- (Complete in Triplicate) Permit No._-7IZ- ------------- --------------------------------- Date " " ---------�- -------- This Permit Expires 1 Year From Date Issued Date Issued_.6_/� 7� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . ---_-. `A _ - i -.--- - .. _ -« ------------------ CE NSUS TRACT Name-- --=--- --�- -- --------- PhoneAddress --- -------------------------- -- City- ---- .---------- Contractor's Name_:__ ------ -------- License Installation will.serve: Residence `. Apartment House.0 Commercial ❑ Trailer Court ❑ i �,... .}. . ., , Mote!••E -Other----=------- - .- = 4- r Number,of I' f t ruing units:, -___Number of,bedrooms_..5'__._Garbdge Grinder_.6/�P_Lot.Size--------- Water Supply:.P Characteof soil Iola depth of 3feetme SandSilt - :. --- ---------------------------- Private. M p �❑ ❑ Clay ❑ Peat[] Sandy Loam (� Clay Loam ❑ Hardpand-'1 Adobe El Fill'Material_.._ If es, -' --- Y type---- --------- -------- --- -- ,.. (Plot plan, showing size of let, location of}system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION'- (No'septic tank:.or se/epage pit permifted if public sewer is available�within 200 feet) W PACKAGE TREATMENT 'j ] SEPTIC TANK j>] x ' - !`` 6 -------- -Liquid Depth.=-- -------•- ' -Capacity_ &C? "-P:- -- 1 TYpe- - __Material---_ .Lc� x t No. Compartments-.__ _-------- r Distance to- nearestWell' -fav Foundation__a ___�___ ----Prop. Line_� �' i LELINE �'"� - ' ` { t ; --------------------- ACHING r, [ Nof.F�ines. `-- Lengt _ eachlin� _-ie--- _ to Length - �J_ . a t ------------- D' Boz 1.._ T - e'Filter Material___Sim �y t' To ! --- f Yp - .- ._- :Depth Filter.Material f- ' a r t ,, 1 Distance,to nearest: Well_:_. � � 1 _-- -Foundation��' -� - Property Line �� TAT ... Depth_/- _ _D4n-reter . �Y I f Z` -- Number _: _:• Rock Filled Yes No Water Table Depth--_.-.-- --- - - ( -- -------.Rock �� --------=------- Distance to nearest: ' -f .. {. T WeIL- ` -- ---------- ----F�o undation_ In ----- P REPAIR/ADDITION (Prey.Sanitation Permit#____..____--_-'_ F r -' r Date ,' ;,. Septic Tank (Specify Requirements)-----6--------- --------- -- ' Disposal Field (Specify Requirements)--------=-- --------- , ------- -- ------ ------ -----=-------------=--- ... _____----------______________ . �. _ __.______-__ _A ____ --_ _ __ ___ ______________________________ _____________________________ { ------------------------------------------------------- - -------------------==--` (Draw existing and required'additiori on reverse side) F I hereby certify that I have prepared this application and that'the work will be done in accordance with San Joe uinCoun 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 perforrhance of;the'work for which this'permit is issued 1 shall not employ an to become subject to Workman's Compensation.' laws .of Caf fornia." p Y Y person in such manner as Signed---------------------- -=--- ------------ Owner - BY - = ----- . (If other than.owner) ----- - ----- •� r ; FOR EPARTMENT USE ONLY r. APPLICATION ACCEPTED BY__ -%:. s I . DATE,- :,31 1 DIVISION OF LAND NUMBER--------- ---- - --------- -------------- ;. ------------------- - ---------- , DATE ADDITIONAL COMMENTS__________________________ # ----------------------------------------------------- --------------------------------------- -._ Final Inspection by:- ' ------- ----------- - ---- - - � .-: EH 13 24 JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M