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ti FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------- (Complete in Triplicate) ! Permit -----------------=------------ Date Issued1--?_7__ 1 -------------------------- -- This Permit Expic.�- res 1 Year From Date Issued i; Application 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: ' . b, r JOB ADDRESS/LOCATION-----_ '�" ' CENSUS TRACT---- !Owner's Name-..1---------- G ----- .- --- -I----- :, ------- ------------------------- on Address------------- City- - T zip------------------------------ Contractor's -------- ------Contractor's Name-------- �r*� -_4f7�Gicense #_3Z-8� ---Phone----------------- r --------------- Installation will-'serve: Residence fid' Apartmeht House [] Commercial ❑ Trailer Court ❑ Motel E] Other---------- -=-----=------------------- :Number of living units:------f---_----Number of bedrooms- -Garbage Grinder------------Lot Siie_----------- ------- Water Supply: Public System and name---------------- - = ----=----------- tt - ------------- -----------•----------- - --------------------- --- ---Private Character of soil to a depth of 3 feet: and ❑ 'Sift❑ Clay ❑ Peat E] Sandy Loam E] Clay Loam ❑ e Hardpan Adobe C] 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.) NEW- INSTALLATION: '(No septic tank 'or seepage pit permitted if'public sewer is available within 200 feet,] •"PACKAGE TREATMENT [ ] SEPTIC TANK [ ]. Size___ _ - -------------------------------- �.� Liquid Depth----------------------- ------- ------- ----- ---- - Material.._.. _w... _.._.._- NaCompartments..�._ _ Y - C,. Distance to nearest: Well--- ----=------=-=------- --=---=------- Foundation -=----------------.-----Prop. line " == LEACHING LINE [ ] No. of Lines--------------------------- Length of each line------------------------- Total. Length --------.----------------------------- 'D' __-•------- -------_----__-'D' Box.----------Type Filter Material------------ --- Depth Filter Material--- -=__-- i .------- ;j Distance#c� earest: Well-.--- _--_ '_--.-----Foundation_-- _ _-Pr:operty Line:--------_ -------------------- SEEPAGE --- - ------•-- SEEPAGE PIT [' ] Depth-- _--i--Diameteri-Number------------------------------ Rock Filled Yes.❑ No'❑ c ' Water TdbzleDEpth = Rock Size f Distance to nearest: Well ---- "7ound tion---- ---------- 7. Prop- Line-------- t -. REPAIR/ADDITION (Prev. Sanitation-Permit*_ • ------------ ------ ---.`Date- ] - - I Septic Tank (Specify Requirements)-'---- r ------ -- -= - -- - 7 -- _-- --------------------------------------- •--------- -----------1 Disposal Field (Specify Recvilmerits]_'_ R'- �,� _ - -- --- x as-- -----= ----------= ----------------- ----- --- --- --- - -------------------------------- -- ;" (Draw existing and required additit rrgn-°reverse-sid�e)- -` 1 .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. Homeowner or licensed agents signature certifies the following: i+ ".I certify that in the performance of the work for which this permit is issued, I'shall not employ any person'An such manner ds to become subject to Workman's Compensation,laws of California.". Signed- ---------------"---------- Owner } By-t - -------Title---AV_Z ----------•---------=----- --- (If other than owner) i 'FOR DEPARTMENT USE ONLY .APPLICATION ACCEPTED BY---7_J'-� - - ----------- ----------------- f-------------------DATE.---- DIVISION OF LAND NUMBER-------------------------- -- ----------- -----------•- --- k----------------- ------DATE-------- - ADDITIONAL COMMENTS-------------------------------------------------- -- --------------------------- - ------ -------. ------- --------- ---- - - --------------- --- ---------------------- -- --' --------- - - - ------------- -- - -------------- --------- --------------------- -inspection bY:--------==-------- - ----'--------- ---- ----=---- ------- ------- - ----=---- Final 7 ' a EH 13 24 SAN JOA. DISTRICT F&S 21677 REV. 7/76 3M t