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FOR OFFICE USE: FOR OFFICE USE: N.cPPLICATION FOR SANITATION PERMIT r.r G�IfS -- - ------- - - --------- (Complete in Triplicate) Permit No. l ----- --- --- Date Issued.T/_= 7d"/ ---- 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. is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: jGn - ------CENSUS TRACT-------------- JOB ADDRESS/LOCATION �� I Af� 7�w � wner's Name - - - Phone Address_.-__-_. 1f _�._.. = - - -- - cityTQCL�i�i'/ ZiP �� T-- (.4�/V ----- ------.License # ---------------- ----- -Phone----------- ------------------- ontrador's Name ---- - - -- -- - - ------ - —stallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-------- ------------------- --- ----- ---- umber of living units:..-l_:--_--Number of bedrooms-- -----Garbage Grinder---. Lot Size- _____ � *Water Supply: Public System and name----------------- -------------------------------- ----------------------Privatex ('haracter of soil to a depth of 3 feet: Sand ❑ Silt ❑.. Clay 0 Peat❑ Sandy Loam Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material--------....If yes,type----------------___.__--___- T per` (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) EW. INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �f -TACKAGE TREATMENT [ ] SEPTIC TANK Size -Z_44" Liquid Depth ------------_.___----_._ Capacity./&OV_.C--ni0aYPe ---------------------Material------------- ----- ---No. Compartments -- - -`--- -- ---- ------- ---� Distance to nearest: Well -._ _._ - ----------------FoundatioP - J_.. �T---.Prop. Line__ --- ` � 6 t LEACHING LINE [ ] No. of Lines.. �__------------- Length of each line.- ___--_---Total Length ----------7;Z7 'D' Box-.----------Type Filter Material-------------------Depth:Filter Material-------------------.--------------•--------------------- - --- Distance to nearest: Well_V/v.?... l -Foundation---2� w-------Property Line--_- S SEEPAGE PIT [ ) Depth_ ___--_--__.Diameter..-_-_-_-.- ---- Number ._-_--_,_-__ _- _-__:--_._- Rock Filled Yes ❑ No❑ WaterTable Depth------------------------------------------ ----- -----Rock,Size--.-.------------------------------------------- Distance to nearest: Well-------------------------------------------Foundation------------------------- Prop. Line_.--_._.---_--__---_--. -IEPAIR/ADDITION (Prev. Sanitation Permit#------------------------------------------=-----.Date-----------.---------------------------------) septicTank (Specify Requirements)---------------------- ------------ --------------- ---------------- __----------------------------------- --------- ------ ----------- ------•------ Disposal Field (Specify Requirements)-- ----- ------ -- - ----- --------- ----- ------- - ------ -------- ---- - ---------------- --- ------------------------- --- - ----- ----- ---- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this aptlication 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 a work forwhich this permit is issued, I shall not employ any person in such manner as —to become subject to Workman' o pe sation law California." Signed--------- --- -- ------------Owner_ I - - - - - Title - --- - - -------- ------ - - -- (if other than owner) FOR DEPARTMENT USE ONLY .APPLICATION ACCEPTED BY -- -------- --- DATE ---�+� � : -- -�_•....�< - ---------- - -- - -- - ---- - ------- DIVISION - - DIVISIONOF LAND NUMBER.---- ----- --------- -- - - --- --- -- - -------------- -------- -- ------- ------- - DATE---- --------- ----------------- ----------- ADDITIONALCOMMENTS . . --- -- ----- - ---- - ---------------- ----- -------- --- -------- ------------------------- ------------ _---------- ------------- - _ ----- ------- ------- ----- -- ------------ ---- ---------------- ---- ----------- ----------------- -- ------- ---------_--------------- ---- - ----------- -------------------- ------------------------ --------- - - ------------ ------------- - - ------------------ ----._..-. -` �5 Final Inspection b [= �'�- ;�: - - - ---- ------.Date- -/ v - P Y= EH )3 24 SAN JOA UIN LOCAL HEALTH DISTRICT F6S 21677 REV.7/76 3M