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FOR OFFICE USE:r ��.tFOR OFFICE USE: — APPLICATION FOR SANITATION PERMIT et Permit (Complete in Triplicate) Date Issuedlll.:/ -� --------- _.._ ----- --- --------- ._........... ..... This Permit Expires 1 Year From Date Issued .pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. —pis application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: SOB ADDRESS/LOCATION ._.__. _`_ _ CENSUS TRACT _ )wner's Name - ---- --- -• -- Phone - -- - Address----- --- S0 - 7 "I - - City,-? —"` zip �j Z 3 / - :ontractor's Name.- - - 1�,� -Phone J - - - License # � 7 ? �U'��_7 - -nstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other -- - - --------------- lumber of living units:------I.------Number of bedrooms_.�J.._.Garbage Grinder---- Lot Size------' ��C!L2 J --- --- 'Water Supply: Public System and name------------- - --- -------------------- ------ -- ------- ---- --- ------ -------------------- ------ - -----------..Private, 'haracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe P� Fill Material.. ---------If yes, type------- --------------- --- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) lkl- EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) V%. 'PACKAGE TREATMENT [ ] SEPTIC TANK [Xj Size--------->---.X-_ __. - ---------------- ---- Liquid Depth_67v- - - - 1�3 Capacity_L -+( - --- _._..Material.0 Z _<- Compartments...___.-. _. _-_-___-W Distance to nearest: Well_...____�G7tS...._ _____ _________Foundatidn.___.1 .___________ Prop. Line__ +.._.___- — � r LEACHING LINE TK No. of Lines --------'L'----------- Length of each line,-------S15_._.-------- Total Length __ ----- _ --------------- J� 'D' Box----t/_.Type Filter Material.. .. ___ ..Depth Filter Material.. ----__---- .-------------------- _..._..__..____ i � Distance to nearest: Well____ _ � _ •4, -Foundation ---- Line__c�_. ._.__.__-.__ t� SEEPAGE PIT Depth__Z,_5..r.__Diameter_ _ _ _ _..___Number_--_._.--------------------- Rock Filled Yes ( No �r / Water Table Depth-------- ------ -- ------------------- ---- -----------Rock Size3- l- ----- 16111 Distance to nearest: Well_. />-,o---- -- --------- ____Foundation___ ------------------- - EPAIR/ADDITION (Prev. Sanitation Permit#._.._...- --- ....__ ----- Date-------- __--- ------- ------------------- _) -eeptic Tank (Specify Requirements)--- --- ---. - -- ------------ - -------- ------- - -------- - - ------ ---------- -- Disposal Field (Specify Requirements)------------------- - ------------ ----------------------------- ------------ ----- -- --------- - ------- - -------- - ---------- -- --------------------------- --- -------------- -- - ---------- ---- ----- - ------------- (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 ardinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: 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." ''`fined - - ---Owner ....Title.. if other than owner) FOR DEPARTMENT USE ONLY 'RPPLICATION ACCEPTED BY-- ------ -11 - ------ - -- - -. .---- ----- ------ ----DATE DIVISION OF LAND NUMBER ----------------- - ----- ------ ---- --- ---- -- . - ------ - - ------ ----DATE.---------------- DDITIONAL COMMENTS.-- -- - -- - ----- - - - -- -------- - ----- - -- ----------- -- ------ ------------------ --------------------- --------------------- ---- --- - -- ----------- - ------ ------------ --- ------------- ------------------------- -------------------- -------- --------- ------------- ------------------ --------- --------- - ------- -- ------ ----- -------- --- --------------- ------------------- ------------------------------ -------------------- ------- ----------------------------------------------------- ______ ______ - -------- - - - - - - - ---- - - - - nal Inspection b — p Y: �-� 4' - - - - ---- ------ -- - -- -- - - -Date. -, 4 --fes/,j---------------------- EH --- - ------ ---- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M