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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------------- - - H(Complete in Tri'plicate) Permit No.7__7_r�:--- ------------------------------------------------------- " 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. 549 and existing Rules and Regulations: -----CENSUS TRACT- ----- ---- -- ---------- JOB ADDRESS/LOCATION-- �(D..L�.�.-----�- ''`-.'-�"-"-'�`,"-7 --W----------- ----------=--------- Owner's Name.___ . ._ ci� - - - ------ � - - - - - ------- ----Phone ------------ ----------- Address --_----- = ------ --------------------- ----------City------ ZiP `5 ZC------ If- Contractor's Name--- ------ � , -----------------------License #_. -7�/------Phone._�� 13j- --- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------------------------------- .� ----Garbo a Grinder------------Lot Size_s 1�-- �-- -------------•------------ Number of living units:--__.________Number of bedrooms__,,, g ---- Water Supply: Public System and name------------------ ------------ ---------------------------------------------------- -----------------------------------------------Private [ — Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy loam [E��Clay Loam EI Hardpan ❑ Adobe ❑ Fill Material.-..---- --If yes, type---------------------------------- (Plot ----------_ ._(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must,be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth --------°---------------- Capacity---------------------Type-------------- _ ___Capacity---------------------Type-------------- --------Material------------------------._No. Compartments A--------- ------------------- Distance to nearest: Well._ -----------------------------------------.-Foundation--------y,___----------Prop. Line ---------------------- � A LEACHING LINE [ ] No. of Lines--------------_x_.__------- Length of each line________________r _______Total Length-------- :_:________ 'D 'Box------------Type Filter Mater..ial_,--.e-------------Depth Filter Material-------------------.---------,-------- '--------------------- Distance to nearest: Well---------_------------;-,:---.Foundation- --------- ----------------Property Line---------,�--------------------. SEEPAGE PIT [ ] Depth----------------Diameter-------- -----------Number-------------------------------- Rock'Filled- Yes ❑ No WaterTable Depth---------------------------------------------------------Rock Size------------------------------------------------ Distance to nearest: Well------- -----"------------------------------Foundation------------------------- Prop. Line----------------------__-- REPAIR/ADDITION (Prev. Sanitation Permit#____._--------------------------------------------Date---------------------------------------------- Septic ---______ ____________ ----) Septic Tank (Specify Requirements)------------- ----------------------------------------- - T -t ---- - ----- ------ -- ------------------------------- Disposal Field (Specify Requirements)----- -- — -- ----�_�6_c_�L1Aw..--�- �_� - -- -r -------------------------------- ------------------------------ ------------- ---------------------------------------------------------------------------------- ------------------------------------------------ (Draw existing and required addition on reverse side) j 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 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 arkman's Compensation laws of California."Signed--------- -- --- ---------- -- ----- ------.------------- ----- ------ -----------------Owner �J By--------- -- ---- - - -- --- - - ----------------------------------------------------- Titler- (If other than owner) FOR DEPARTMENT USE ONLY ��pp APPLICATION ACCEPTED BY -----------------------------------DATE. _--/C_..r f ---- -- DIVISION OF LAND NUMBER---------- --- -------------------------------------------- DATE. ADDITIONALCOMMENTS----------------- ------- ---------------------------------------------- --------------------------- ----------------------------- --------------------------------- -----------------------------------I-------------------------------- ------------------- ------------------------------------------------ ----- - ----------- ---------------------------------------------------------- ------ --- FinalInspection by------------------ `-- - ---- . -- ----------------------------------------------------------------------------Date.---��-- ------ --- 1 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT fa 21err REV, 7i76 ann