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7 FOR OFFICE USE: ✓ FOR OFFiCC-USE: i APPLICATION FOR SANITATION PERMIT ---------------- ........ l - Permit No- " ----------- ----•-.- _ (Complete in Triplicate) - - ------------ Date Issued.. _,�.__1��.� ' .-----•-•.--.---.... .................... This Permit Expires 1 Year From Date Issuer! r Application is hereby made to-the San Joaquin Local Health District for d 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: JOB-ADDRESS/LO x ... ................CENSUS TRACT_...'... -- ----- .......... C ION....:- --� . ... . ........ ..... . . .. _ Owner's Name.....q .... .--- . .. ............... -- --- ---...-'---=---------- - -- -- ------Phone.-- ------ ------ Address_. � --- " Zi -------- Contractor's Name.... - - '-' ---- --'- . .._.License #- --®. ��/-.1_. .Phone.- -._ • -� Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other... - ------- ----------- Number of living.units: ...1_........Number of bedrooms..-....Garbage Grinder............Lot Size------- ------------ -- 1 Water Supply: Public System and name...................... -----------------------------.------------.------------------Private Character of'sdil to a depth of 3 feet: i Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam . Hardpan ❑ iAdobe EJ _ _ ._... 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) .... PACKAGE TREATMENT [ ] SEPTIC TANK ....Liquid Depth.'_) l Size � � X_ �(."�.� - ----...---- ' - � Capacity. a----Type.--- --- - -- MaterialG*�.-_ - ---:No: Compartments_.._ Distance to nearest: Well. -------.,_e. ............ .......-_Foundation..._ ........Prop, Line----............. ..-_.-..._. j i i 3--------------------Length of each line------- Total Length /LEACHING LINE No. of Lines .� - -..---.._ i 'D' Box.. __..YType Filter Material. Depth Depth Filter Material._.--: .. ....._... ................ ... ...... Distance to nearest: Well------- - - ` Foundation-.--..:.__-�-- --------. -.Property Line. f SEEPAGE PIT [ ) Depth... Dia:neter.._-_. -_ umber.... ---___ -------------- Rock Filled Yes No Water Table Depth------•------- ' -- -_-_-------------------Rock Size.--- � � .._.. ----------- Distance to nearest: Well---- Foundation............. ..... .....Prop. Line..____................ r-- 's REPAIR/ADDITION (Prev. Sanitation Peiirmit#_._._-............................ ...............Date--------:-._....---------:_..-.--------.--__.) Septic Tank (Specify Requirementsl...._+a----------- ------------------------------ --- ------ Disposal Field (Specify Requirements)-................... - ---------- ........ " ......... ---------- ------ ....--------- (Draw existing and required addition on reverse side) r I hereby certify that 1 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 "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 alifornia." Signed-----�1_31lf Owner r; ---------- ---- M By......._.. Title .. ... ........ • -- other t an owner) F R EPART ENT USE O Y I APPLICATION ACCEPTED BY............. . .... ._:..... --- __-.. _ ...---.--- -- - .... .a!r __ ---.........-.-. ---...DATE ....--..I .�.� 7� ---------------- I DATE. ---- ------ ADDITIONAL COMMENTS : -- . ...- DI ISION F LAND NUMBER._...._._._... - �- f� :Z r ------•------------------------------------------------- ------- - -- -------------- -----------.- -------. ----- Final Insp6ciion by:....-' Date... -_. �.✓ -. FH i3 2a SAN AQU1N LOCAL HEALTH DISTRICT F&s 21677 xev. 7/76 3M