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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No...7 ..... Je-- ------------------- Date Issued--�_--/f------- ---- -------------------- This Permit Expires 1 Year From Date Issued oplication is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: J ------CENSUS TRACT------------------ -- _ -- 3B ADDRESS/LOCATION.. .- ... ./.... .._ .._..__. ner's Name.... . ... ........ ---_;fe ------------------------ ------- Phone...--- ----•----_--•---- -- �ress____.. ------- 1...-- _ . -----city Z - ontractor's Name._....... _ ..License #-yy �� .-- -Phane_�1. �i allation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other........---- 11mber of living units:.......I.......Number of bedrooms..---T Garbage Grinder............Lot Size-------- G ..✓3. �_ /.. .. -er Supply: Public System and name-- -- --- ---- ------------------ ---.. . - ----------------------------------------------- ------------._.------_--------Private (� ioracter of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam - 1 Hardpan ❑ Adobe ❑ Fill Material.. ._ _._If yes, type_____---------------------___. rot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) .FIV INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 9- RAGE TREATMENT [ J SEPTIC TANK [ ] Size .. -. ... _�_10..____.._..__...___Liquid Depth._Y_ --._...._.._....__� mm Q Capacity-/.(, O TYPe-�------ ---...Material--- 1(�_ - -•--------No. Compartments----!_%?,1--------------------6 Distance to nearest: Well............._.__._ ....._ --- ---------Foundation_-___- _.... .. ..Prop. Line-------------__._-------k 'MCHING LINE [ ) No. of Lines — Length of each line.._.__"( 0_______________Total Length _-----..--------•--' 'D' Box..#r.._---Type Filter Material.:_`..___. Depth Filter Material-_.... ----------------- -----------.----.--C1 Distance to nearest: Well------ .-___. Foundation____________________________Property Line....____-.__. ....._..---------.- :EPAGE PIT [ ] Depth._.._A.b....Diameter---�/H----Number-....__ __ -------------------- / Rock Fillet! Yes ;� No Water Table Depth-------------------_------- ------------------------Rock Size----- ---1__ G Foundation----- - ----- -- _ Pro Line. ---- - Distance To nearest: Well (;j___.f----- P• :'AIR/ADDITION (Prev. Sanitation Permit#-----------------•--------..--.---- ---- --........Date-----------------------.--...--.-----.--------) tic Tank (Specify Requirements)---- - -------------------------------- ------- ---------------------------- ---------- isposal Field (Specify Requirements)---------- -------- --•--• --- ----•------------------- ------ -- -- --.. ----_-------- ------ . - --------------------------- ------------- ---•----- ---------- (Draw existing and required addition on reverse side) ! :reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Minances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents gnature certifies the following: :ertify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as become subject to Workman's Compensation laws of California." nned ------ ---._..__----------- ----Owner _0 .-... Title ( f other than owner) OR DEPARTMENT USE NLY p� rr'LICATION ACCEPTED BY------- . . . . ... .. I6_.-._ .0LA. -------•------------- --- .DATE ..--- ----/. --1 ...? IVISION OF LAND NUMBER_............. ----. DATE---- •------ DITIONAL COMMENTS--- ---------------- ---- �--------- ............. -..---------------- ----- -- --------- ---- --- -- -- __... _. �y al Inspection by:..... Date ; --- -- ------- - --- -- -- - --- ----- . ----- ---••-•---•--- ------- ------- --------•---------- -----------------• F6s 21677 REV. 7/76 3N - ------ -- - 713 24 °SAN JOAQUIN LOCAL HEALTH DISTRICT