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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- --- ----------------- ------------------ - it (Complete in Triplicate) Permq Date Issued.;_--�i; . --------------------------------------------------------- This Permit Expires —Year.From,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: f O B AD R- Gu m r?�4p/ 1 J CENSUS TRACT JOB ADDRESS/LOCATION.�.7/ ' � _ _�-----aw--- -5..--- , Owner's Name ---------------------- ----- ----- ------ -------------------------------------Phone CI 11 ,, ' Address ------------------ -City--------1 --------------------------ZIIP------------- -- - ------------------ Contractor's Name--:----- - ------ ------ -- -------- - ------(20 - License #__� ZZ-4---Phonel------ - i I s Installation will serve: .i Residence Apartment House.❑ Commercial ❑ Trailer Court ❑ Motel ❑ F Other------` -------- ------------ Number of living units:_'- 1.__---.Number of. bedrooms -;�'-,Garbage Grinder------:-,._:-Lot'Size.-..---4--" '-~�~�" "--_--__- s vy Watbr Supply: Public System and name_______________________ Private - ---- ----------------- -- ------------.------_----- l Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [�Clay Loam ❑ y` Hardpan ❑ S Adobe ❑ , Fill Material------------If yes, type______________ : s (Plot plan, showing size of lot,'1onationoVsystem in'relation to wells, buildings, etc. must be placed on reverse side.) 7. NEW INSTALLATIONT-qi septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT € . ( ] - Liquid De`p [ ] SEPTIC•TANK---TT e'-- ----:----Size- Material -------- -..No. Compartments- ------------- ---------- -th------- Capacity----- YP gyp. k O' { Distance to nearest: Well-------- -----------------------------------Foundation----------------------------Prop. Line--------------------------- LEACHING LINE. [ ] No.`of Lines- - ---1 . --------------------J of each line..--.--.----------------------Total Length.-_.___-------------_---------------:-f 'D' Box.............Type,Filter Material---------------------De"pth Filter Material t Material-------------------.------_---- --------------------------' i�h Distancetonearest: Well Foundation _ Property Line__'------------------------------ SEEPAGE g i PIT j ] Depth ....................Number...:._____ _.__________- Rock Filled Yes ❑ No❑ I 1 Water Table Depth--------------------------------- ----------.___.Rock Size-------------------------------- i------------ Distance to nearest: Well----------------------------- --------------Foundation-- -------.----.Prop.- Line--.-------------------__--- f REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date-----------:---------__-=:------,------- )it Septic Tank (Specify Requirements) - ------------- --- -------:--- ------------------------ --------------------- ----- - �' ----- ------- Disposal Field (Specify Requirements) ► = - -- ----- ,ems- ----------- �a,aa --------------------------------------------------------- , -------------------------------------------------------------- ------------------------------ ----"--------- ----- - ]Draw existing and required addition on -- . .re'verse side) 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 il 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 to become subject to Workman's Compensation laws..of California." Signed---- ---- ------------------ ---------- - = -----------Owner ByTitle ----------------------------------- ------ ' o (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY._......_(1 -.- ------ ----------- -- -- - DATE---- ' r i DIVISION OF LAND NUMBER...-------- ------------------- ------------------------------------------- --DATE-- ---- --- --- ---------------------------- ADDITIONAL COMMENTS------------- ----- ------------------------- i` '------ --------------------=------ - -i+ . i . -------------- -- ------------------------------------- - x-1 ` - ---- '1 ---------------- Final Inspection by:: - - -- ----- =_ - ------------------------------------------------ EK ---------- - Date-_--------------- ------ -- ----- EK it 33 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 23677 REV. 7/76 3M