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ss , FOR OFFICE USE: w FOR OFFFICI ISE: PLICATION FOR SANITATION PERMIT q '/ (Complete In Triplicate) Permit ........................................I................ No.�.../..-.Y..�.d Date Issueds�.,3/-�,9 ......................................................... This Permit Expires 1 Year From Date Issued r 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 RuFles and Regulations: _ _ � _ JOB ADDRESS/LOCATIQN..:.".Y.'.�. ....._.�h .`�- j,: .....�GG� ..'.;• .. .......CENSUS TRACT.......................... .. �^� Owner's Name.... 1.. .../ �..G.. ...... .................................I..... .............................:..................Phone....�5. Address...............)o-`J.........w.......& T/T.._.......... ............. ...............City.?--Mc. . . .................'Zip.............................. Contractor's Name.._ . Lr / .-. .................. ................License #s� �' ..�� .PhoneL .S _ Y?,6..1..... Installation will serve: Residence (V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other.............................................. /I�y A C. Number of living units:......1........Number of bedrooms.3.... Garbage Grinder............Lot Size....Z! . . . . ..................... Water Supply: Public System and name.. ..'.............:.................... ....................Private ........................................................................ Character of soil to o depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam EX Hardpan ❑ Adobe ❑ 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 INSTAL4ATION; (No septic tonic or seepage pit permitted if public sewer is available within 200 feet,) y PACKAGE TREATMENT [ ) SEPTIC TANK. [ I Size ..I X. =---................Liquid Depth.J..�l/......... Ca acii /. ,;t t.......T . P Y - YP��A�Material..........................No. Compartments......��...... ..... .. - T' Distance to nearest: Well.......C) ...... ................:....Found� ��Z-r.. . . _ Prop. Line..5p. t LEACHING LINE [ 1 No. of Lines . • ....................Length of each line.. .�...................Total Length .. .��milt ................... . • 'D' Box..l ... ..Type Filter Material../ /�1�epth Filter Material.. ..../l�........................ .........,.......... Disianceto nearest: Well..�< !.�. .T...Foundation.. .0-�^-7- •Property Line..... �.. •..•-- SEEPAGE PIT ( ] Depth...........i'...Diameter............:.......Number................................ Rock Filled Yes ❑ No [ WaterTable Depth..........................:..:...........................Rock Size................................................ Distance to nearest: Well...........................................Foundation................ .........Prop. Line............... ........... REPAIR/ADDITION (Prev. Sanitation Permit#................................... ..:............Date...............:........:...:.................) Septic Tank (Specify Requirements)...... . ='....... .. """"--" Disposal Field (Specify Requirementsl...................... ................................_................ ....................I...... ........................................................................................................_........................i.......................... ........................................... ......................................................... ..........---....;.......................................... ---------............................:...................................... .... (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.....t.:. ]~�. r ...... ..........................................Owner By...................................................................:.................................... Title..... ... ................................................................ (If other than owner) OR DE ARTMENT SE ONLY APPLICATION ACCEPTED BY...... ....... ......:............DATE .... ....---.. ............. DIVISIONOF LAND NUMBER........ ...:: .................................. .......................................................DATE............................. . .... .. . . . ADDITIONAL COMMENTS.... ..................................................... .... . ........ I .....................................................................................................................................:........................................... ....................... . ....... ............................................................... ...... . .. . ...... .... . ..... .. ......................... .................................. ... ......... FinalInspection by:............................. .. ... .................... ..............................................................Date...,�l.y..�..3�."'7.`�. EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F6s 21677 REV 7/76 ]M