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4— I FOR OFFICE USE: FOR OFFICE USE: ` APPLICATION FOR SANITATION PERMIT z --------------------------------------------------- - (Complete in Triplicate) Permit --------------- - --- -'---- ---------'--'--- - � Date Issued---3"��7� ---------------------- --------------------------- This Permit Expires t 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: " 22- -CENSUS TRACT.-----''---- --------------JOB ADDRESS/ OTION. Owner's Name--Ae-�-_: _- t c - ' _ --- --- ne.g� '"~�gZfa:---- Address_ ---- _ - �r City --- -= --- ---- -.._Zip �rf� � ' vy Contractor's Name__ x -- - - --------------------------------------------- icense #lie10 Phone:.Q L � Installation wilf serve: es dence rGZP3,-- Apartment House❑ Commercial ❑ Trailer Court ❑ . � + �� i - Motel � ----'---- Size - - �_ s, ❑ Other----- ---- -------- f Numberof-living units•.- -- :__ ___"Number of. bedrooms. Garbage Grinder ,_ __Lot Size.- --._.-......._:_.__ ----____ __ ----- Water Supply: Public System and name-- -------------- - ,� ,. ____Private n Character of soil to a depth-of 3,fee:�S'a`nd 0�. Silt El Clay E] Peat ❑ Sandy Loam ❑ Clay Loam ° Hardpa'ri ] Adobe Fil! M eri`al' * Ef yes, tYpe_________________________ (Plot plan, showing size of lot, locationrof system in relation to-wells, buildings, etc. must be.placed on reverse side.) ' NEW INSTALLATION: [No "se tic tank 7tz `or seepage' it ' �• r s p permitted if public'sewer is available within 200 feet,] [ l '..SEPTdC TANK.. ,]. Size--'-- ------------------:-------------------- Liquid Depth = . PACKAGE TREATMENT Capacity_ = ater.ial---------- ------'--------No. Compartments--------a'-'j-------------: : I i ;< < or53 Distance to nearest: Well__ "r _ -----Foundation_ / Prop. Line. LEACHING LINE ] No. of Lirile }---- .`Length Qf each ine :'____Total Lf�th- _/. __�_ _____________ ` i # 'D' Box. � -Type Filter Material: ___ �0 i .. 4YA "----Depth Filter Material----------- --- ;------------ '-.-- ------ t [ Distance to nearest: Well----------------------------Foundation---------_:-----------------.Property Line.-.------------------- -'-------_-_-. t - SEEPAGE PIT :[ k]' Depth -- - iD:iameter.________________ _Number___:___-.__-___ Rock Filled Yes. No P . .. - - ❑ -- f ".'+'�. -sem . ` 'Water Table Depth.---- __ ' - ______ Rock Size----- - i Distance to,nearest. Well ---------------- ----a--------------_.-_-Foundation--------- -_----.Prop. Cine---------------------------- REPAIR/ADDITION.{Prey SAni.tation-Permit#_L. _ -. -� ,-------- ------Date -_ ---------------------- ) j J SepticTank [Specify Requirements]_-----_'y_--- -- -------------- --------------------,-------- ---------=--- =--------------------- --------------------- r G I i Disposal Field {Specify Requirements)_-_1_ ______ ----i - - ----------------------------------------------------- ! - 1' [Draw existing and required addition-on reverse side} I hereby.cert'sfy that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,. State ILciwit and Rules•and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the fol owing: "I certify that in the performance ofaFie'work-fo,'r which this permit is issued; I shall not employ any person in such manner as to become ubject a td- Workman's Compensation;,laws of ..California." t Signed_ -- ---- BY -------------- - ---------------- T------ itle " --------.------ ------------- i � - � �• '�{If, other•"tlian�;owner) � � � '- � - t t . ..... .� _, FOR DEPA NT USE O - APPLICATION ACCEPTED-BY--' - ' _ - ._. DATE. r �� $ DIVISION OF LAND NUMBER-------------------- ------------- - --- --- -- ------------ ---- -----DATE . _ ADDITIONAL~ COMMENTS -•--------------------=---------------------------------- ------ . ---------------------------------- ------- ------------------------------------ ----------- ---------------- ---------------- -------- ------- --------- t ------- - -- --- --- ------------ ----- _- �-;---- i -----=------- ---------------------------------------- = ' ----- - - Final Inspection by: =------------ C / `_"� '' _ _-Dat --------- '- LI" k f SAN JOAQUIN LOCAL HEALTH DISTRICT . Fas 21677 REV, 7