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FOR FICE USE: FOR OFFICE USE: bF f PPLICATION FOR SANITATION PERMIT � } ....................................... r `r Permit �' (Complete in Triplicate) -------------- --- .......---.................. Date Issued--�l rte- -� -------------------------------------------- ....... 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. :is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: Y --...-..---- DB ADDRESS/LOCATION........�7�cx'.�.-.:......� - -----------------------CENSUS TRACT............--•------ [F..�1....�.G.��!.11------- wner's Name r ...........................Phane-0. ----------• --------- ZiP----•---•------ -------------- ddress----- J� •----- ................. .--•----- ------- tY y �V on'ractor's Name--- ...... � — ....License ZPhone. . .. ..................... stallation will serve; Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motes Other_I*C4.,.Z.t; C_ umber of living units:................Number of bedrooms.....---....Garbage Grinder............Lot Size------Yi�- rater Supply: Public System and name.-- ----------------------- -------------------------------------------...........-------------------:--PrivateA haracter of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material.. .... ... If yes, type.............. .............. lot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ,ter EW INSTAL;ATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} // IV, J ACKAGE TREATMENT ( ] SEPTIC TANK [ ] Size.... x_5,4._ '�---•-----•------ --------Liquid Depth..-y..........-.....a ... --- --- ts Capacity. P_ .---.-.TYPe-�'�F<4SrMateriai- •- ................;No. Com artmen ------ ------- ` Distance to nearest. Well.-../4f Prop. Line---------- .......... ----t-------- ...Foundation- . ..y _ACHING LINE ( ] No. of Lines ..P ...................Length of each line_.,i%- --------- .-_Total Length D' Box-.1........Type Filter Material. .r� vgpth Filter Material................... ............. /�---- ----_- ---.--- Distanceto nearest: Well--/i --...Foundation-..��...------•-----.Property Line. �----------- - ---•. ..... EPAGE PIT [ ] Depth........ .......Diameter.......-....---.....Number...........-------------..------ Rock Filled Yes ❑ No❑ Water Table Depth.----------- •---- -----...............Rock Size.- ............ -------_-----•-----•--..------- Distance to nearest: Well-------------------- ....Foundation....-------.... Prop. Line......-.....---------•----• EPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------_ ..,_....-._Date---_-------------- ---__ ---- ......... eptic Tank [Specify Requirements] --- -------------- -----•-•----••-•----- --------- __---------------------------- )isposol 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 )rdinances, State Laws, and Rules and Regulations of. the San Joaquin Local Health District, Home owner or licensed agents :igna ure certifies the following: in such manner as 'I certify that in the performance of the work for which this permit is`issued, I shall not employ any person o become subject t� kmlanCompensatioin laws of California.'. signed------ �!/"....r7,,,,r ...... Owner ..,Title...................- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.... .............................. ------DATE ..�.^---------'~��:. �----.......... DIVISION OF LAND NUMBER ............ ....... ............. .....--------------•---------.-------- DATE------------------ ......_........... .-. ADDITIONAL COMMENTS............. ........ _-------------------- ---------------- ................. ...................... ..................... . .... .. -• • L ".....' ........._..Date... � �r Final Inspection b EK 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT / &5 21677 REV. 7/76 3M