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FOR OFFICE USE: .. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- ------------------ - (Complete in Triplicate) Permit No..78'._./53 ------------------------------ ------------------- -- This Permit Expires 1 Year From Date Issued Date Issued . -_ ...7y App l�cation'is- reby made to the San Joaquin Local Health District for a p& -it`to construct and install the work herein described. This application is made in compliance with County Ordinance No. 349 and existing Rules and Regulations: JOB ADDRESS/LOCATION------ _CENSUS __ _ ENSUS TRACT_._.0(_-3:!�� k Owner's Name.: - --------- -- ----- ----- _ ------ Phone----- ------ - -- - ------��------ city. -- -----------------------------Zip Contractor's Name-- ---- - _ �_ License #--- 44 �' ' ------ --- ----- ----------- - - ---------------Phone ------- ^- Installation will serve: Residence [] Apartment Hou ❑,- 'Corrmer1 ❑ Tr iter Court ❑ Jw. Motel F1Other-- �..} -► = Number of s living units-----------------Number of.bedrooms_�' ----Garbage.Grinder_ S' lo :_________________ _____'_ ._ . -- ----------- Water -- ,4[- ❑--- upply: Publie5ystem and name ------INv- - ---� Private Character of soil to a depth of 3 feet: ' Sand ❑ Silt ❑ Clay 1? Peat ❑'� Sandy Loam ❑ Clay Loam ❑ =' # Hardpan ❑ 3V Adobe 0 - Fill Materiaf�-=--__.If _ _-_ _--_ I (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'4or see 1 ge pit permitted if public sewer'is rh available within 200 feet,) ll/ PACKAGE TREATMENT ( ) SEPTIC TANK [� [ Size--- --- «- ' { x -_- - = ----------Liquid Depth T-=/=- - 4 ----- Ca acitY- I6aA-------Type. -No: �-- Compartments = = t Distance`to nearest: Well.._...,.. 90 -q__._.. - F ndation:_'_�_:.t�. -__Prop. Line--------- _. ) #^. , LEACHING LINE [!J�No. of Lines_,Lines._..--- _ _.Len.gth of each linefiTotal Length. l_��__ -- iE D' Box-_:_. _Type Filter Material-_ ! __� Depth Filter Mater.ial._: _ _ ------------ Fo� Line Distance to nearest: Well ; ndation_"_ ) Pro er .___-_ - # iameter 1 erJ t �' SEEPAGE PIt Depth __ -____: J Rock Filled Yes No p ; : ...�, Water Table Dep'th_______________ _ Rock size:__._ + - -------------- Distance to nearest:Well._•_..__/,_-:5 _ _Foundation_:'_" t ' = Prop. Line--- REPAIR/ADDITION (Prey:Sanitation Permit-#-- - ------------ :_______ _________.pate------ :'_:__._, Septic Tank (Specify Requirements) ---------------=---=---- = =---------- ------' == _ ---- ----------- ---------- ---------- --------=--------------------- = Disposal Field (Specify Requirements)______________________ -------------------- ---___-__: = ,- - -- -------------------- ' ------ ----------- ------- a ------------------------------------- ------------- ------------- _________________ : ' --------------------------_------------------------------------------------------- (Draw existing and required add'ition-on reverse side)-3. s` I hereby certify that'] have prepared this application and that-the work will be done in accordance with San Joaquin County r 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 has to become -subiect to Workman's Co nsation_ laws of California." Signed_----------------- ---------- ..... r Ow � BY ----------------- - - Title (If other than'owrier) FOR DEPARTMENT USE ONLY'�'+ APPLICATION ACCEPTED, BY �- -- -— - } DIVISION OF LAND NUMBER: -----------------------------------=----------------------------------DATE---------- ADDITIONALCOMMENTS- --------`---- --------------------------=-=---------------=----------- ------------------------------- ------------------------------' .. w i ________________________________________ Final•Inspection by:_-.:: ..- .—�_�_ ------- - ---------- ----- f��-� ` ------- ----- - -------------=-----------bate. . EH 13 24 N JOAQUIN LOCAL HEALTH DISTRICT F&s 21677 Rev. 7/76 3m