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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �Gt�� ------------- Permit No./nr"16_ (Complete in Triplicate) Date Issued-- ---------------------------- ---- ----------------------- ssued--------------------------------------------------__.._._. 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 ADDRE55/LQCATION�:t `c' ` ��`{'''^`` CA -�--------- ---------------- - CENSUS TRACT - t Owner's Name. -Y s - _ ---------------------------------- Phone--------------------- -----------., _--- Address.' = --'`-1� � ...... -. ----- -City----- ----- ------------------Zip---------------------- or � -- --- Contractor's Name -:-_.___ -- ---- -------------- -------License # _.Phone Installation.will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------- . ----------------- ---- Number of living units:____ /__ _ _Nu ober of bedrooms.-.__ ___Garbage Grinder ---- _Lot Size._____�4 -�..____._._ ------------- t - - F. \. _I_,J ;'j-----------=---Private Water Supply: Publi6,System and name----- -- ---- -------- = y mak_ --- Character of soil to a depth of 3 feet: Sand Silt ❑ Clay ❑ Peat ❑ an y Loam Clay Loam ❑ # -Hardpan ❑ Adobe ❑ Fill Material__ --------- yes, p (Plot plan, showing size of lot, location of system in A ion:to wells, buil ' gs, etc, must be placed on reverse side.) NEW INSTALLATION: '':[No septic tank or'seepage pit 'rmitted if p lic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] ' SEPTIC TANK' I ] Ne____--- - -;`-- ----------------------- ---------------Liquid Depth -------------------------- opacity--------- - :---- Type------ - erJal.--- ----------- -IVo. Compartments----------------------------------- tG Distance to nearest: Well--------------- --- ----- ---------Foundation-----j--------------------_Prop. Line.........•---------------_-. LEACHING_ LINE' [] No.,of Lin ------------- q_, . -_Length o each lire------------------------------.Total Length----------------------------------------- es D' Box--------- Tybe Filter Material :_-_ Det Filter Material---------------- - -•------- -----. --- i Distance to nearest: Well-------------- �. .Founclio i__:-__ _----__-+._-:.--Property Line._______----._-------------------- r SEEPAGE PIS [ 1 Depth Diameter-------- Num " } F. : r p _----._ ber----------------- —}—_.----a Rock Filled "Yes No ❑ Water Table Depth--------------- ------------------------------Rork Size---; ----'------- --------------; ------- i Distance to nearest: Well--- ---_--`------------------ _.Foundation.----I_=:_----= -'- Prop:}Eine--.---------------- C. REPAIR/ADDITION (Prev. Sanitation Permit#----- )` '_Date---------- ___f____-------------------------- ---------- ___________ --- Septic Tank (Specify. Requirements)-----------=-- ' --------------------------- i Disposal Field (Specify Requirements) �f/ -------- ----------------------=------ -- --------- -------------- '�-�1 --- �---- — -------- ------ -' ------------ ------------------------: - --- ---------- . „ ----------- ---------------------------------------------- --- ------------------------------------- -< ---- -------------- =--- ----------- ----- --------------- --------------------------------------=--------- ----- ------ -------- ---- ---------- t t (D,aw existing qnd required addition on reverse side) I hereby certify that I have prepared 'th 's application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws; and R/es, nd Regulations of the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following:"I certify that in the performance of work for which this permit'is issued, I shall not employ any person in such manner as to become subject to Wiirkman's C ns tion laws f California." r Signed--------------- ------------- -------- -=---- -- --- - Owner By-=------= = !!{ � Title--- --------------------�- ---------------- - ----------- (If other than owner) ` F I FOR DEPARTMENT USE ONLY GG APPLICATION ACCEPTED BY - ---------------------------------------- - -DATE.----D-_ - DIVISION OF LAND NUMBER DATE ADDITIONAL COMMENTS-- ---- ---- ---------------------------------------------- --- --- - ------------------------------ ------`-------- ---------------------------------------------- ------ ----------- -------= ------ --- -- �-� - -------------------------------------- ----------- -- -- - ----- FinalInspection by:--------------------_ -. _ .. - -------------------------Date------------------------ ------------------------ EH 13 24 SAN J LOCAL HEALTH DISTRICT F&s 21677 REV. 7i76 3M .a.