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-FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT rrll ----------------------- ------ ---------- --- (Complete in Triplicate) Permit No..._�l.-.-.2-- -- ----------------_--------_ ------------- --- Date Issued-./ _-.--------------------------- ----- This Permit Expires 1 Year From Date Issued / plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T s application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: - - - --- CENSUS TRACT..--- ---------- ----------- - in6 ADDRESS/LOCATION.. 7..-1.�v-.- - �- - ----- -- -- -- --�`"`�-� - - - - / ✓ner's Name.------- - ------ --------- ----------- ---------- --Phone �o�a_._' C7&.------ Address _ v `-- '------- ---.-City----- --- ------------ --------------Zip------------------------- ----------- ------ - - rntractor's Name------ --- --------------- ---- -------- .--- `--------- -- -- ------ #.f^'-.7. ._j "3 - Phone_.-1.�L-�4-��_--- —stallation will serve: ResidenceApartment House ❑ Commercial F] Trailer Court Itel ❑ Other----- ---- ----------------------------------- imber of living units:.------f ------Number of bedrooms-._.F---.Garbage Grinder------------Lot Size----- CC1--- ---- -- Water Supply: Public System and name.----- ---- - - -------------------------------------- ------------- -------------------------------- -- ---------.Private, -.iaracter of soil to a depth of i�- eet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ p� Hardpan(& Adobe Fill Material------------If yes, type (Plot plan, showing size of lot, location of system in relation to wells, buildings,'efF. must be placed on reverse side.) 7 p seepage p p p ,available within 200 feet,) EW INSTALLATION: (No septic tank or see a e it permitted public is � rACKAGE TREATMENT [ ] SEPTIC TANK ,I ' ize.___ _..___ _ ---------- Depth._S____---------- _ "�--- Material._C -------.No. Compartments------------ -------------- Capacity.� _ -Type.--/(- - 1 r / Distance to nearest: Well__...__..G�---------------------- -Foundation.____._./0_._-___-____Prop. Line!__- .. ,+ e LEACHING LINE j No. of Lines.__.....______..-._. Length of each line___._._ ,k.............Total Length._.4 -_----------.----------- 'D' Box_._L�ype Filter Material-_ `t--Depth Filter Material-------------/J---------------- Distance to nearest: Well _J f.__._..___.Foundation...__/a_ t:_______Property Line----- - �EEPAGE PIT Depth._ �� _ _Diameter_....._�.3_�'.._Number_-_.._.. - Rock Filled Yes � No❑ 0 _. Water Table Depth - Rock' Size.; X�Jam.---------------- Distance to nearest: Well_......._l s__�--.___________________Foundation.,,_-___ _. -f --.Prop. Line 7 - EPAIR/ADDITION (Prev. Sanitation Permit#_...-._____.__---------------------------------Dgte___.____.___-____-__---------=---------.-----) Ptl ( P. I YReqr r - -- :. ------------- = ;Disposal Field (Specify Requirements) - ==_ ; t _ = t_. ---------- -------------------- -------------------------------------------- ----------------------------------------------- ------------- --- --------------------------------------- --- - - --------------------------------------- ---- ----------------- - - ------------------ -------- -- (Draw existing and required addition on reverse side) 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 subject to Workman's Compensation laws of California." Signed ------- - _... Owner Title r --------------- ----- --- -- -- ------ --- By ---- -------- --- ---------- f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - - ----------------------------- DATE /� % -------------- DIVISION OF LAND NUMBER.------ ------- ------------------- ------ ----------- - DATE - ADDITIONAL COMMENTS------- -------------- ----------------- --------------------------- ---- -------------------- ----- ---------------------------------------------------------- - - ------ -------------- -- -- -- - -------------------------- ---------------- -- ------ --------- ------------------------------------------- --- ---- --------------- -------------------- .... ----------- --------- - - /------- --- 1� ,- --- Final Inspection b -' Date_._--�..-� - - py--- ----------- EH 13 24 SAN JOAQUIN L C EALT DISTRICT F&S 21677 REV. 7/76 3M