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10 � FOR OFFICE USE: f FOR OFFICE'USL: APPLICATION FOR SANITATIONIPERMII ................................. ............. 2 N Permit No"?9..A (Complete in Triplicate) ......................................................... Date Issued S.' •....................•,..•............................... This Permit Expires I 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 ReguI do s: .......... . . .........................CENSUS TRT..........................JOB ADDRESS/LOCATION........ 1. Owner's Name.... ....T . D.e....N,Q'. " .......... ... ......................... .. ............. .. Phone... i ,Sa '�c! Address............... .. .. T!`�../...... ......1`......................................................City..��7/}f. .............�...... Zit. . p...... ............:...... .. Contractor's Name........ ............_....r�.........r•.:.,5.......................... ......... ........License #.o?��..S�v Phone. S 'A.Sr�w4•�j�/..... X-r • .- Installation will server Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ // Motel (] O-�ther.............................................. Number of living units:..[.............Number of bedrooms.\.. Garbage Grinder............Lot Size...............a: ... ............. Water Supply: Public System and name.................. ........Private .......................................................................................................... Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material.. .... ....If yes, type................................ )J Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.(• ,Q VEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,( 111 PACKAGE TREATMENT ( ] SEPTIC TANK �� I 1 Size .......�k.ylo�d.X�.....................Liquid Depth....�Y............V%. Capacit1't.........Typ4;.O1....Material..........................No, Compartments......... ................. • Distance to nearest: Well......� )...r. r.............Foundation.. /G7. : . ..r......Prop. Line.. 07..'4..7.... ....� EACHING LINE ( ] No. of Lines . . ..................LengihPf each/line.�j '. .......Total Length .. �.<4�i...�T.... ' 'D' Box./.. ......Type Filter Material1, 9/� p !� 10 .. a th Filter Material.......�............................................. - -+ Distance to nearest Well../. �!.. .r...Foundation S. ......Property Line.... ................... iEEPAGE PIT ( ] Depth.......... .....Diameter....................Number................................ Rock Filled Yes ❑ No?i1 Water Table Depth.!..:..................................... ...............Rock Size................................................ Distance to'nearest: Well...........................................Foundation..........................Prop. Line............................ 3EPAIR/ADDITION (Prev. Sanitation Permit#................................:.. ...............Date..............................................) iepticTank (Specify Requirements)...... ..................................................................................................................................................... DisposalField (Specify Requirements)...................... ................................_.............................................................................................. ....................................................... ............................................................................................................. ........................................... ........................................................ . ..................................................................................................................................................... (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 Jrdinances, 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 arkman's Compensation laws of California." Signed........ �'''.....� .� ..........................................Owner By........................................................................................................ Title.......................................................................... (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.... ` ............ .. .... .... .. .... ......... ...................................DATE ..,J—....',Z.Q...:..79.............. DIVISION OF LAND NUMBER............. ......................... ...... . .................................................. ...... DATE............................... ................ . ADDITIONALCOMMENTS......................................................................_....................................................................... .......... ... .. ....... .................... ............ .. ......... ..........................................:..................... ... . . C .. .......... ..................... ................ .......... .. . ................................ ............................................................................. ............................................................................ .............. ........................ ... .......... FinalInspection by:......................... ... ...........................................................................................Date......................... ................. ..... EH 13 24 SAI J JOAQUIN I r)('.AL HEA."H DISTRICT F65 21677=. 7/76 3N