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. } -16 FOR OFFICE USE: FOR OFFICE USE: E APPLICATION FOR SANITATION PERMIT --------------------------- ---------------------- r� �7 (Complete in Triplicate) ` Permit No./-- ---..----.-- -------------------------------------------------------- `, - �- Date_lssued-w---),`-�J --------------------------------------------------- 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 Count rclinance No. 549 and existing Rules and Regulations: i 119 V t s ! JOB ADDRESS/LOCATION -- --- ---- ----------.CENSUS TRACT._.-,,.-. --- �. i - ------ - ----Phone--��- - ------------------------- Owner's 8302 Address Q/ . ,... may, ,.moi --------------License #---a-7/S-_- s�-.- -. �` Contractor's Name'___,_--- {�, �" - -- _ _-- -- -- ----------- 3�-T n -- ------ Installation e Installation will serve: t Residence [��Apartment House ❑ :Commercial ❑ Trailer Court ❑� t x ?• Y Motel ❑ I Other ----- - ----------- �.. Number of living U' nits:_-'-- ----Number of. bedrooms:- Garbage Gri deer .--- Lot Size.... - /.QCT . b --- ---- --------- W citer -------- Water Supply: Public System and name-------.--`--- -- r - Private El p j 0 t El.. Y ❑ ]] y = ❑ y R _ 1 Character of soil to a de tIi of 3 feet: Sand Silt Cla Peau Sad Loam Cla Loam ❑ a i Hardpan ❑ Adobe _ Fill,-Material- --�------If yes, type �'---------------------------- (Plot -- ------------------- --(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be!placed on reverse side.[ NEW INSTALLATION: "(No:s ptic tank or seepage pit permitted if public sewer is available within 200 feet,) i f PACKAGE TREATMENT [ ] 4-SEPTIC TANK.- [ ] c Size---------------------------------------___--___- Liquid Depth---------------------.- va Y `r � CaPacitY------- ----- TYPey. ------------Material---------.': .------ -- --No. ComPartments.--------1r ----- :-- ------------- - � Distance to nearest: Well--- ---=--- -------------------- ---- Foundation------- ------------------Prop. Linel----- = -------- LEACHING LINE [ ] No. of Lines_; --------------------------------Length of each line---- -------------------------Total Length.----_------------------------------ D' ________-__---------------_ _D' Box------ Filter Material'----- ------------Depth Filter Material______________________ c ( 3.. .,,�. ---- - ----------- - - .- - ---.Property Line------------------------------- ---- I ` Distance to riearest: Well-----------------------------Foundation_._,__.___________ c SEEPAGE PIT [ ] Depth----_-.---- ----Diameter_:__---------- ----Number------- - Rock Size tRock Filled Yes❑ No Water Table:Depth--- ---- -------------- ---- -- ----- -------------------------------------- Distance to nearest: Well ---------------------.-------------------,.Poundation------------------_------.Prop. Line---------------- ------------ -------- ---------------------- • � � � -. � -- �� Y .- REPAIR/ADDITION (Prey. Sanitation Permit#-----. ----- ----- ------------=-------Date------'---- --- :--------------------------f Septic Tank (Specify Requirements)-- --- ----- - ---=----- - - ----------- v� -i Disposal Field(Specify Requirements)-- - -- - - - -- ---- r , ..� .- --- i I ' (Draw existing qnd required addition 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 [tegulcitions� 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 wfiiih`this`perrnit is issued, I shall not employ'any person in such manner as to becon, s ject to Worknjans Compensation laws of .California.'; ' k � Signed ;- -Owner. t t ----------- BY ---------------- -- ---- ------- i - ,` `_Tule f c {If of eii r than owner) FOR'DEPARTMENT USE ONLYt ] ' APPLICATION ACCEPTED BY- - --------------------------------- -------------------DATE.... ----------10- - DIVISION OF LAND NUMBER--------------=---------------------------------------------------------- ---------------------------------DATE-------------------- ADDIT[ONAL COMMENTS -------------------------------------------=---------------------- ---- 1 , --------------------------------------------------------- --=---------------------- ---------------- ------=------------------ ------------- ---------------------------------------------- ------------------------- ------------------------------ Final Inspection by - - -------------- -----Date----�j-----J�-------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f8S 21677 REV. 7/76 3M }