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FOR OFFICE USE: FOR OFFICE USE: a APPLICATION FOR SANITATION PERMIT " (Complete In Triplicate) Permit N .... -/-. ....- � ........ ............. . ........ . ................ / -7 .---- .. . .. ............. ...- - ....... This Permit Expires 1 Year From Date Issued Date Issued- .- 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: J08 ADDRESS/LOCATIO . ._... �� CENSUS TRACT................_..._.. . _. Owner's Name G ! � //f/C.. ............... .......Phone ... :•:•:•• ............ Address.. :.j.-1 . . _�. <" h-..W . ... City -. L'd ......... ..Zip...`... Contractor's Name..... ,..�.........�! izv%l .... 1—License #-..,,2��";a2.�.`f--..Phone...-- Installation,will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--• .. ........... ........ ................ Number of living units:........- Number.of bedrooms_ .........Garbage Grinder......... Size................ . .. Water Supply: Public System and name................. ........................................Private [ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay (X Peat ❑ Sandy loam D Clay Loom ❑ Hardpan ❑ Adobe ❑ 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: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ J Size.............. ........ .......................... ........Liquid Depth.._........ . .. .. r � Ca acit . ......Type.......................Material....... No. Compartments.. ._......._._........ . . .. .`� Distance to nearest: Well ...................... ......... Foundation............. . .. ...Prop. Line._._..__.............. LEACHING LINE [ J 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 Piz [ J Depth................Diameter.:..................Number................................ Rock Filled Yes ❑ No E\ Water Table Depth.................... .. ................................Rock Size- ------------ - ------- -....-- _-_ Distance to nearest: Well.. .......................... Foundation.... .__.._.. ..... ....Prop. Line.............. ............ REPAIR/ADDITION (Prev. Sanitation Permit# . ........._.............................. ... Date.. .................... ...................... ) Septic Tank (Specify Requirements).............. --- - -- - ----- -- ----.._ _------ _.... .-.....------ ---... . . ---•- --------. Disposal Field (Specify Requirements)..... „�I 77�1G- /.- --11r -..•-. �' �i A' {Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed ag t 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 to Workman's Compensation laws of California." Signed ............ _ -- r. ............_....... ... ..............---•--Owner � . By..,�(''..... /�.p. . --..Title._.._...... ---_---._....--- ..... .......... . _.._........ G (If other than owner) FOR PARTMENT USE ONLY APPLICATION ACCEPTED BY.... .. ...................DATE .d� ........... ... ><. DIVISIONOF LAND NUMBER....................... ......... ................................................. DATE....... ........ .. ---._.....-------- ......... ADDITIONAL COMMENTS. .................. - ............... ...I ..................... .-----...-................................................... ................................ ......................__.................... • ..--------................ . ....................... ....... ..........................,.-.......................... ...................................................................................................... ....................................................... .....................:..............� ----------------- ------..--. ----...... .. ••----....... .- ....--- ...................... Final Inspecnon by: .......... Date----------------- ---.------------ EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F65 21677 REV. 7/76 3M w �.