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`FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,G _ (Complete in Triplicate) Permit --_-.5-�� ------------------------------- ----- -- --------- - ----------- This Permit Expires 1 Year From Date Issued 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: JOB ADDRESS/LOCATION.----___ ------ _------------------------------------------------ -- ------- ---- -------._CENSUS TRACT �v Owner's Name------ N_-..elliO4-t�'----CLj. * -- ' 1 - - -----:---- --------------- -Phone- Address--- hone_Address--- ------------ F , City.. p *�.. Contractor's Name T• �---LSr��.� ----------- ------------License Installation will serve: Residence ❑ Apartment House ❑ Commercial Z Trailer Court ❑ Motel ❑ Other---- Number ther---Number of living units:---------F--___-Number of bedrooms.- ------Garbage Grinder-------------Lot Size-. _--_?�_ � Water Supply: Public System and'name--------------- _____ Private [i - - ---- Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ - Clay Loam ❑ f Hardpan (] Adobe;o 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.) R ! NEW INSTALLATION: t(No#septic tank or seepage ,pit permitted if public sewer is available within 200 feet,j PACKAGE TREATMENT [ ] -43 SEPTIC TANK-[.:] Size------------ Liquid Depth '------------------ Capacity------ -------=------:Type------------ -"= ------Material--------------------------No. Compartments--------- " -------- Distance to nearest: Well ----------- --------- --.------Foundation_ - --------------Prop. Line------------------------ � . LEACHING LINT: � [ ] No. of Lines ----------------...--------Length-of,each IinEa-_=_---------------------------Total Length.-' ,-------------------- 'D' ----------- _ -'D' Box____.--.-;:_Type Filter Material--------------___-.Depth Filter Material_.------ - _--_--. -- - --------------------------------------- Distanca to nearest: Well _---'-------------Foundation --_____ ------------Property r Line_ ---------------------------- - ---- P SEEPAGE PIT [ ] Depth----------------Diameter-_------_----- ----Number---:------------------------- < Rock Filled Yes ❑ No ❑ i a [ Water Table:Depth --------------------`------=---------------------:-- Rock Size:-- ---------=---- ----- --- -------------------- Distance,to nearest: Well-=------ --------- - = - ----------Foundation------ -- -- Prop. Lihe--------------------------- REPAIR/ADDITION {Preva Sanitation Permit#---------- ---------------------------------------Date---------------- I Septic Tank (Specify Requirements)-.-_--:----_ .-_- --- vDisposal Field (Specify Requirements)_.- 4� ------- --- -------- --- - ---- _------,- --------------------------=------- ------------�.�X-��_(_ `�` -----------------------------------------------" (Draw existing and required addition on reverse side) I 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.to Workman's Compensation .laws of California." Signed --- ner -- ----------- - OW 9 BY ` --------- :, Title -----=- - -----'-------------- - ------ - ----- --------------------------- (if F other than owner) - ^' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_' ---------=------------- ----------------------------------- -------------------------- DATE ---- DIVISION OF LAND NUMBE ------ -------- DATE DATE ----- T__.- �` - 1,.--.__--.--'_-_ '- -- _.._ --' ADDITIONAL COMMENTS-.. - " �- -- --a''�----.��_-.------� .�� {��ra.-------_a ' ------------- cA - -------------------- ------- •- ---------- --=--- ------------ ------------------- -------------- -------------' y-------------------------------------- -- ------ ------------ -------------------' ------------------'----------- Final-inspection by,-_ - -= -----:-- '--- -C . -----------Date.---- 7 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV, 7/76 3M