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FOR OFFICE USE: FOR OFFICE USE: [ APPLICATION FOR SANITATION PERMIT p d . (Complete in Triplicate) Permit No..Z.�..��..l...-... 1� Date Issued. ............. .... .. ........... 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 County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIOQ9, Jl ------- ------- ... _.. kvvENSUS TRACT.. .. - �/Owner's Name............. ------ ------ - ----=------Phone. ......-- i_ . Address--... .- .....Cit Contractor's Name...- ------ ------------ - ----------------License ......Phone-_z1or ?o��-, . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El/ Motel ❑ Other---------------- --- - - - - ------------ - . Number of living units:_..-./--......Number of bedrooms:, /....Garbage Grinder_...--_------ Size.Apib . .X717 ............. fWater Supply: Public System and name-- ---- - -=---=---------- ----- ............................ ... . ..-.� Private ] Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clays` Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Materiar.. .... ....If yes, type................................ (Plot plan,-showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] I NEW INSTALLATION: (No -septic tank or seepage pit permitted if public sewer is available within 200-feet,] ` PACKAGE TREATMENT [ ] SEPTIC TANK >1 Size.-.._/.. �._.�+��.... ----- -- ..... ....Liquid Depth J. Compartments------:.-. ... ....1 Distance'to nearest: Well-----��_'..47...... ... ..... Foundation..- 6 `... --------Prop, Line-.�.... '�+.- LEACHING LINE [ No. of Lines --.....� ------....Length of each r �r ---Total Length .. -�,�C�..................... D' Box__ .Type.Filter Material. a/ dam -Depth Filter Material...._ -------.........._.-..-.-_.------------ ..........,. Distances to necirest: Well....`................Foundation---aR.�O--...._ .....:-._Property Line-...... ............ SEEPAGE PIT [>' Depth..X5.....-Diameter..13.3...........Number....._c— -------------------- Rock Filled Yes,] ' No ❑ ` Water Table Depth Rock Size...-, --------- -------------- � l Distance to nearest: Well......Ito-6-•.........................Foundation.... .�......... ...PrO Line_.. ...... .... REPAIR/ADDITION (Prev. Sanitation Permit#--------------------- -•--.--.... ....--...------Dote---------------=----------------.---------..._.) Septic Tank (Specify'Requirernentsl.. 1':........:.... - Disposal Field (Specify Requirements)- -------- ----- ---- - - ........ .. ---•----- ------__------- -------- --------1----••---------------- - ----- ..................... 6 fir, -----------•-------------------- ---------- ....................... lDrow 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-6gulations 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 as to become subject to Workman's Compensation laws of California." Signed .---..... .. _,,"t r` �- - -------------- -----------------Owner BY•------ � �.-c...! 4 Title C ' f (If other than owner) a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.f. "--,/ i( --_ , DATE .,� dS-._ �..................... O .. :....... DIVISION OF LAND NUMBE ---------- --- - DATE.'- ADDITIONAL COMMENTS..............:.. -�•- .... Final�lns ectian b- ----- --_-N- �-�--...---... .' - - ------ ...........-...............----------------------------------------. - - ---.:-----:-- --- ------ ----.... --... ---------------------------- ------- µ ......_._ p Y:---.. v 1.-..._ . . ........ ...........•- - - - ...... .-Date...------- - ...........-....- EFS 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT res 21677 REV. 7/76 3M it �l�E �