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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR"SANITATION PERMIT -----------'-----------=--------- - t Permit (Complete in Triplicate) --------------------------------------------------------- Date Issued____--- 6--_7 2 ------------_---__---_____----------------------------.__ 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC lON ..__o2cD_____--_ __ -_-..CENSUS TRACT---------------------------- ----- Owner's Name. -- - .Phone_$"�- ?39.l- ..rr}} ----------- -------------- Address---D�- .y�. J City - ------ ----------------- --------ZiP------------------------------ Contractor's Name__ __ _ -- ---- License #___ _ � g?---Phone--- 1447 ___Phone___ 1lS-' V�__._. Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Ur Motel ❑ Other----- -- - - --- - ------- ----. ---------- / Number of living units:.,7oZ----Number of bedrooms------------Garbage Grinder----------_.Lot Size-------- ---X- - ---d Water Supply: Public System and name---------------------------------------------------------------------"---------------------------------- ------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑_ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material_.._.....-__If yes, type---- ----------------------------- Q (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 permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size______________________ --- ----- -- -------------Liquid Depth._____________.___-____-. Capacity---------------------TYPe----------------------Material---------------- ------ --No. Compartments--------------------------------- Distance to nearest: Well-_ _---------------------------------------Foundation.______.____.___________.Prop. Line___.___________._ __ LEACHING LINE [ ] No. of Lines-----------------------------Length of each line---------------------------._.Total Length _.__._. `D' Box------------Type Filter Material-_ Depth Filter Material_____ _-----------_--------______________________________ -� Distance to nearest: Well-______--------________.__-Foundation__-__..______.____.________Property Line__.________.__________._____._ _.' SEEPAGE PIT [ ] Depth----------------Diameter _._____Number_.-_____,_,.______._____ ______ . Rock Filled Yes ❑ No WaterTable Depth-----------------=---------------------------------------Rock Size------------------------------------------------ ----- to nearest: Weil-------------------------------------------Foundation--------------------------Prop. Line.-----------------_-__-- REPAIR/ADDITION (Prev. Sanitation Permit#---------------------------------------------------Date.-----------------------------------.--------.) 1 Septic Tank (Specify Requirements)----- r ---------------------- - --- ------------------ Disposal Field {Specify Requirements]-- �4 -- --#---------------- ------- - - -- --- (Draw existing and required addition on reverse side 1 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: "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 ject to Wor an's ompensation laws of California." Signed--r--- -- ------- ------ - ---Owner / By--------------- `..•cr ` --- ------------------------------Title- .-----------------_-- ------------------------------------ (if other thaA owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- -----.DATE C Z--/�'.+]----------------- DIVISION OF LAND NUMBER - -- ------------ DATE.__. --- ------ ------ ADDI 10AL CO E TS -- --------- --------------- - ------ ------ /' { �-� �� ri u ----------------------- -- ---------------------- - t ----- ---------------------------------------- - _ Date r_Q/Z 7 Final Inspection by:___-___- -} -__ EH 13 24 SAN JOAQUIN LOCAL H ALTH DISTRICT F&S 21677 REV. 7176 3M