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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �- C J� J (Complete in Triplicate) Permit No................... . . Date -------------- --------- ---- This Permit Expires 1 Year From Date Issued 1pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION __t�F�W 2 -------------- �' == � `--.----------------------- CENSUS TRACT ------------------------------ )wner's Name --- ?r: --------- ------------------------------/ ----------------------Phone-------------------------------- Address -�- -- /------` -C-�, - � --....City c /- �r ' =-------•---• --Zip -•--------------------------- Contractor s Name----�1�t_t -----`. ; = ------` ----sly---•---License #_3 Z ZZ-(:__Phone-------------------------------- nstallation will serve: Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------ --------------- ---------------- ,lumber of living units: ....I_------Number of bedrooms....5----Garbage Grinder------------Lot Size_..__.___.'_____________ Vater Supply: Public System and name---- -------------------- ----------------------------------------------------- _ ------Private ©� Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam E�t-- 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.) -SEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) W 'ACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---_---------------_---------------------------------------Liquid Depth_ __ ._...--_----..-__-- Capacity- - --- -- ----- Type ------ --- --- Material--------------------------No. Compartments- --- ----- -- ------------0 Distance to nearest: Well_ ----__ --------------------------------Foundation-------_------------__- Prop. Line--------- ---_._.__-._--_. Till LEACHING LINE [ ] 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 PIT [ ] Depth -------- ------Diameter___------- -------Number_---------_--- _----- -------- Rock Filled Yes E] No ❑0p Water Table Depth---------- ------------------------------------------ -.Rock Size.------------------------------------ Distance to nearest: Well------------__._---- --------------- ------Foundation......................... Prop. Line___.__._.______-_____. , REPAIR/ADDITION (Prev. Sanitation Permit#-------- I--------------------- -------- P' ieptic Tank (Specify Requirements)__---..._ _---.--.. . Disposal Field (Specify Requirements)____________ ___ ____ _.-- .._. __-__._._..___ ------------------- ,� -------------------- ------------- --: nr - -- --•- = - - - (Draw exi ting and required aditi on a'ah reverse side) hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Drdinances, 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 the work for which this permit is issued, I shall not employ any person in such manner as o become subject to Workman's Compensation laws of California." Signed--------- -------------------------------------- .. Owner --- BY - - - - ------ - --G--. _.Title-- : -e sti - .. (If other than owner) FOR DEPARTMENT USE ONLY �7 77-7 APPLICATION ACCEPTED BY--- - �.0- ----- ----•- - •----- ---- -- - - - DATE �" -- DIVISION OF LAND NUMBER.--------------- --- --- --- ----- --- ------ -- ----- ----------------- - ---- - -- ------DATE ... - -_ -- -- -- -------- -- - ADDITIONAL COMMENTS - - - ---------- ---- ---------- --- ------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- ------- -------•----------------------•---- ----- ---------- ---------------------------------------------------------------------- --------------- •----------------------------------------------------------- - ----------------------- - - - ---- ------- - - Final Inspection b Date.-. _. ..i.... ..�__._,�... ........... P Y � /'- --H 13 24 SAN JOAQUiN LOCAL HEALTH DISTRICT F&S 21677 REV.7/76 3M