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FOR OFFICE USE: ; FOR OFFICE USE: �, APPLICATION FOR SANITATION PERMIT . - -'.�------ �� (Complete in Triplicate) Permit No. .�:._ 5__ ________________________________________�-_.r , This Permit Expires Year From Da Date .. .,-----.- to Issued Application is hereby made to the San Joaquin Local Health,-District cit far,a+permit to construct and install the work herein described. This application is made in compliance with County Ordinarice.No,549-and existing Rules and Regulations: JOB ADDRESS./LOCA ION: 'l' = .:__ `-..__ -------------------------------------------- = - CENSUSTRACT. __... leo v- Owner's Name.----- C�' � = Phone-------------------------------------- y Address---- --- --- ---- � � � '�_ ---- i--- '- - ----- -- ----- --------- ----'----"----'�-- - �City -- -'---"-----;';------- ----: ----- --Zip---,- -- - - '- License # ` j Phone _ _ - Contractor's Name..._ ------------------------------------------� . . Installation will serve: Residence [ ' Apartment House ❑ Commercial ❑ -Trailer Court ❑ . ' ❑ _.___Ga ba e Grinder_________Lot.Size._.;�TY� cr- ;_- Motel Other------------= ----- - ---------- -- -Number of living units:____!.__.____._Number of bedroo�s / __ _ Water Supply: Public System and name ------------ = Y �b = " `------ Private ❑ Character of soil to a depth of 3 feet. Sand Qt Siff❑Clay ❑ t Peat❑ Sandy Loam ❑ Clay Loam f [ Hardpan ❑ Adobe ❑ Fill Material__. ---If yes, type____________________.__.._._._: �E (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-- x _6 _________________________Liquid Depcth -- - 9 --- - ---- Capacity,--/.A � i3 '__.Material f7?.----= No. Compartments -----------� Distance to nearest: Well-----------------------------^w_.+:= -,_Foundation.------- ------------.:_Prop. Line---------- ----------------- D' Box---.- -- -Type Filter Material-_-- ; -------------------------------------------- h line. - - --- gC1------:Total Length.--j-_ - ---------------------1 ! - --- LEACHING INE [ ] No. of Lines-:-A__-._ _ Length o eac----- Depth Filter Material--------------------_ � 3 � `v------------------------ ------ -- ------- Distance to nearest: WeIL _._ �____ _ Foundation______�_4`�_____ __________.Property Line._:_ _ t SEEPAGE PIT �De th__-�_�.___Diameter--�;�__------__Number______ __ - _ Rock Filled Yes No El . : 1 ater Table Depth--- -------------------- Rock Size ------------------------------ arayst:Wal'I.__. % ____-'Foundation_ -------'---'-- --____--:Prop, Line--------------------------- Distance.to rie ' REPAIR/ADDITION (prey Sanitation Pd-rrriifi#--"'a --- "°-- "t-------=---------------------Date--------- ------------------------------------- d Septic Tank •1Specif`ltegdirements)------ -------------'------=----------- - ------ --------------------------- -------- -------- Disposal Field (Specify Requirements) ----------------------------------------------=- ------------------------------------------- ' ------------`------'-------------k------------=-------------`------ ---------- --------- --------------------_-- ---- ------------`----------------------------------------'---_._-- ---- - --- ---- ------------------ ------- _ ------------------------------ -- {= (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 Rules and Regulations of. the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: 1 4 E ' "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 64Workinan's Compensation. laws of California." f Signed--.---- a -'----.. __ Owner By-1 Title---- ------- ------------------ ---------- --------------------- s 1 . (If other than`owner) V ~ FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- = - " DATE. f MJUM ------------------------------------- -,_ DATE = UMBER " . - DIVISION OF LAND - ADDITIONAL,COM .. �- -------------------------- --- ---------------- ----'-------------------------------------- .. --- ------------------------------- ------------- ---------- t -------------------------------------------------'------------_--------- ------------------------------------------ -------------------------------------------- -------------------------------------------- ------ ------ ---------------- -------- ------ -------------------------------------- - J / t Final Inspection by " " '.`� Date F �` ' �� - l = -- -- --- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT 3 F&s 21677 REV. 7/76 W-1, Q3 4