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f I FOR OFFICE USE: FOR gFPICt USt: N• APPLICATION FOR SANITATION PERMIT �y,T, Permit No (Complete in Triplicate) Date lssuedl-�.,r ...................................... This Permit Expires 1 Year From Date Issued _ _Os .� .. �. 19 rWf 1 (.r. Applicatio 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 co pliant with County Ordinance No. 549 and exist Rules and Regulations: ' RACT-.. ......................CENSUS T µ .----... .....-........�..JOB ADDRESS/LOCATION. ................--..- f 2---...- :......PhoneA4C�Lnl:F. Owner's Name..-.._...- i; - '.. Address-. 4p .�e►-._...... c ?0` .............. .:......City zip =y 1 Contractor's Name... ............:.�C [.....--- -•--- .........license #.. .. ..-.-..Phone. . ... ..... . Installation will serve: Residence ❑ Apartment House ❑ Commercial [) Trailer Court ❑ Motel ❑ Other...} - ....- --- =-• Number of living units:.......I-------Number of bedrooms.........Garbage Grinder....--_.-._Lot Size................. ......_.........._............-__-.. Water Supply: Public System and name........:......... .. .. .........................-_......_........---.............-........Private I Character of soil to a depth of 3 feet: Sand ❑ Siit❑ Clay ❑ PeatSandy Loam ElClay Loam ❑ ,.. . Hardpan ❑ Adobe ❑ Fill Material.. .... ..-.If yes,type................................ i (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,} , Sf 4 • PACKAGE TREATMENT [ ) SEPTIC TANK [ ) Siz _...... ... .. .. ............•-.---:---------------------Liquid Depth- . r �„ ...._—No. Com artments `...4 Capacity..J.G.-O.0...._Type /LP.- ...MateriaL _ _ P 1 r Foundation.. r.......Prop. -; Distance to nearest: Well.�.�.............................. : i 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 [ j Depth_------........Diameter....---------- -...Number....-_---..-__.._.-•______...... Rock Filled Yes ❑ No WaterTable Depth...................................._..............._....Rock Size............................... .......... Distance to nearest: Well...........................................Foundation.... ...........- ----.....Prop. Line............ REPAIR/ADDITION (Prev. Sanitation Permit#..•... ...................... ................Dlqte.....--_-..._..... ._--.....-------......... .) i Septic Tank (Specify Requirements)- . ::-.--.....................� Disposal Field (Specify Requirements)................... ......................... ...............----:..•-•••------.........---........._..--........_•-•-........-...._-... k ------------------------------------------------- -------------- - =-------- ------•............. .......---•-----•.:_..........---.._.... ..................................................... ......................... I------------------------ ------..--...........---............---- .....--.....----•-. ...........---••-••-••--••-----.........---........- -------------- .-.-..------ ..... N {Draw existing and required addition on reverse side) I hereby certify that l have prepared this application and That the work will be done In accordance with San Joaquin Count Ordinances, State Laws, and Rules and Regulations of the San Joaquin local health District. Home owner or licensed cgents 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 fto Wo kmar` Com�p-eennsation laws of California." Signed.................:... 4 .....(.¢ Q'� G. �- ------..Owner .- '..-.....Titie...� ....----- ------------ ..--•............... (if other than owner) FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY._ ... .. ------••--- ............. ..............................DATE...... .: '7. .............r...-.. I, DIVISIONOF LAND NUMBER.................................. ..........................................DATE.......---------------------- ...... I ADDITIONALCOMMENTS____................. ...._----- •-----...........--.....---------------------------- .............. -..... ........................ ------.......................................:........................................................ ... . -------------- --- ................................................ •---.-- ...•.-....- • Final•Inspe'i ion by:.. .:... ..' .. --. .......... ......Date -S..3 a..- �5.... ... ............... EH 13 24 IgAttJOAQUIN LOCAs. HEALTH DISTRICT ' FSS 21677 REV. 7/76 3M I 1