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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7. --------------------------------------- ---------- --- ------ -------- -- Triplicate) Permit No.. ----- ---- ---- (Complete in --------------------- -------------- Issued_8-- - �7 - Date -------- --- -- ------_---------------_- This Permit Expires 1 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. 544 and existing Rules and Regulations:: JOB ADDRESS/LO N...:,lQ ------ _ ------------ ----'---- = e. Pa CENSUS TRACT Owner's Name.---- '-- ----- hon ._.... f x {. - Cit --------------Zip---------- ---- Address--------- --- ---- -- ��------ s� Y- -------- r .. Contractbr's Nome----- �- -- c---- --- License #..72 -Phone---------------;----------.------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court. ❑ . I Motel ❑ 'Other - ---------------------` ._- r - _ I ---------------- - . ----- G z a.;. ; Lot Size..-____ � Number of living units:__.. _-f \ Number of.bedrooms_'.- ?..-Garbage Grinder t ^+�tem ci'6cl I� t Private r Supply: Chaaeacter of sol Colla des th of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat -- ---om - p at ❑ "-Sandy Loam ❑ Clay Loam # Hardpan EJAdobe E] Fill Material------------If yes,;type_.. `________________ (Plot-plan, showing size of lot, location of system in relation to wells, buildings;etc. rnGst be placed on reverse side.] NEW INSTALLATION: ' {No'septic tank or seepage pit permitted if public.sewer is available within 200 feet,] fr Li uid Depth------------------ PACKAGE TREATMENT [ ] SEPTIC TANK [ l Size-------------'----------------------------------- ----- q Capacity -----°Type---- A Material--- -=�-_' " -------No. Compartments----------------------------------- I r Distance to nearest:.Well:_____-`_____________ � Foundation - Prop. Line LEACHING_ LINE: [ .] No. of Lines----------------------------:Length of each -- -----,Toto! Length._---------------:-__-------------------- 'D' Box------------Type Filter Material.-___..: .....Depth Filter Material------------------------------------------------------------ Distance,:to nearest: Well-------- -------------------Foundation_-e- --. _y---------------.Property Line -------------;=-----_--- SEEPAGE PIT [ ] y Depth----------------Diameter- ----- ----Number----�---- Rock Filled Yes F71 No E]] Water Table Depth----------------- -------------- ---- -----------_-'= ---.RockSizeI------------------------------ ----------------- Distanceao nearest: Well..'---•-=--------------- Foundaiion_____----------------------Prop. Line_------------------------ REPAIR/ADDITION [Prev. Sanitation Permit#--------------- --------------------------------:.Date-.--`- ------------- >----) Septic Tank (Specify Requirements] --------------------- - -"l'� `T�--T"---- ----- ----------- ------ I Disposal Field [Specify Requirements)---+��---� r ---- ------------- ---------- '"" 11--- -------.. _- -- ---- --------------- ------------- xisting and req Ered addition on reverse side) I hereby certify that-I have prepared this application and that the workWill-be-doneFa it ccordance with San Joaquin County Ordinances, State Laws, and, Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents l signature certifies the fallowing: "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.': I Ownera Signed------------------- - ar+ BY -. ; ---------` Title ------ ------------------ - ) {If o er than �owrier) R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_:"_ = �----------------------------- DATE. - - ... DIVISION OF LAND NUMBER ---- ------------------------------------=----------DATE.------ ------ --------------- ------------------- -ADDITIONAL COMMENTS__ --------- --------- --------------------=---------------------- --- ----------- --------- --------------------- ----------------- ---- ----- = - ------------------------------------- ` --------------------------- ------ �'� FinalInspection b -- ��--------------'�=--------- ----------------------------------- --------------------'----Date-------" EH 13 24 ' SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21166 -- 77 REV. 7/76 3M