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L CE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT--------------------- ....... ... (Complete in Triplicate) s`./a:-- This Permit Expires 1 Year From Date Issued Application is hereby made to.the San Joaquin Local Health District fora permii to constfuct,.and.install the work herein described. This application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations: `Y ------ ---- -------•--- ---- ..-...CENSUS TRACT__..................... ...... JOB ADDRESS/LOCATION..-...... -----� -� ---- - - - ------ �- - Owner's Name. .................:..:..;�.--'-�- :-,.{--i--F...Phone --....... .-.-------------------- Owner's - ---•-- �--- -� ---- ...._"---..- ..... 1. . i J . . -"---- ... .. ... City--- .... ....:..:....... . Zip Address... � - - - - '� - yy F ...--. -...License #Ae11/-1�. ne- . Pho Contractor's Name .f . /�-� Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.. . .. ........ .-------- ---... Number of living units:. .....-------Number of bedrooms... --...Garbage Grinder------------Lot Size �. - .._.-Private Water Supply: Public System and name-- ---- ---------- ----" . ...... Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay-❑ Peat ❑ Sandy Loam [I Clay Loam, Hardpan ❑ Adobe E] 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 permuted if public sewer is available within 200 feet,) f ------- Liquid Depth.../-.... ........... Size ..... �-----�---•---- PACKAGE TREATMENT [ ] SEPTIC TANK [ ] �' Capacity../-am.0.,P----TYPe Mater_ia l_- ma� = •--- ---.No. Compartments artments ----- .----------------- 0 .......... ..-- oa ...-Prop. Line. 5.._�......_.._.-- Distance to nearest: Well_---- ......Ft ) -�-�- � LEACHING LINE [ ] No. of Lines - -..---.�•---_-----.. Length of each 1ina...-•- -�? ---=-f Total Length _1_717---------------- D';Box..---.�.;-��ype Filter MaterEal..._/.��. --.Depth Filter Material--.----/--- ------- - - - ----- ---- Foundation •--------------- - -Property Line.. ........-- -DistancE{to nearest:,Well:_............ ...... , SEEPAGE PIT [ ] Depth. .XAdV.lbiameter------------------- Number...-------- ------------ k Filled Yes No❑ Rock Size..... ....... Vor .. Water Table Depth`".-..---- ----------- --- .... - n 0 Distance to nearest: Well-----. d� -- Foundation_....! .8.. Prop. Line... ..... _-.... REPAIR/ADDITION (Prev. Sanitation Permit .....----------------------- -- -- Date.-... ... . ... ) ............. Septic Tank (Specify Requirements)---- - --------- - ------------ -.. . ----- Disposal Field (Specify Requirements ................. ...... . ........ • --------- I ------ f.----------------------.------- ---- -- ------- ------ --:---------- (Draw existing and 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 Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: _1� "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 mpensatiort laws of California." Signed.-- ---- - Owner -------------- ._..... Title..--.--_-_------- ----------------- --- (If other than owner) e.FCIR DEPA TMENT USE ONLY DATE APPLICATION ACCEPTEDBY---------- ...... ------ ..DATE.- -- -. -------- - ---DIVISION OF LAND NUMBER -- . ADDITIONAL COMMENTS......... ------------------------ _. ................ . ... _ - k- ....................I.......I...........;.- t Final Inspectionby:b ----""--"--" 21677 REV. 7/78 A EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT