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FOR OFFICE USE: 1PPLICATION FOR SANITATION PERMIT FOR OFFICE USE: (Complete in Triplicate) Permit No..� /... -- - . This Permit Expires 1 Year From Gate Issued Date lssued.//./- 49.-'�' 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.. .. ,.. ...�l E ....................CENSUS TRACT.............................. Owner's Name.... ..... ...................... .. .. _..... . _..- d �� ... ...... ..........................••---.. ...------....-.Phone........... Address vl�J a City.. _. .- Zi Contractor's Name........ ....... -C-----5� y66- p6o�7 --...._ ...........� .....p ❑ ......license #./�_S5�•'3y3._Phone.. ................ Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other.................... Number of living units:.... ..........Number of bedrooms.....3..Garbage Grinde.r........._Lot Size..... Water Supply: Public System and name.. .... .............. Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam Cloy Loorn 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 INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ j SEPTIC TANK N11ize ...... ...X .................... . . . .....Liquid Depth.__ . T Copacity...ZXPIP....Type Material.. ..-....No. Compartments...._._.. ------ ... Distance to nearest: Well........ d-� . . - • . ....--...F��tion.----/0. .-f- .. .. Prop. Line. ._�........ .EACHING LINE �(j No. of Lines . ... ��................Length of each line...--......_-................. Total Length ................... 'D' Box....All, ..Type Filter Material.. .. Depth Filter Material..._1.SFD..... ......... Distance to nearest: Well.... 0_. .........Foundation..../Q. "'.-.....Property Line... �............ ,EEPAGE PIT [ j Depth.... .. -..Diameter.............. .....Number................................ Rock Filled Yes ❑ No ❑ Water Table Depth.......... .................... .........................Rock Size..... ................ Distance to nearest: Well..................... .....................Foundation................ .. ......Prop. Line........................... EPAIR/ADDITION (Prev. Sanitation Permit#.................. ...............Date................. ..... ......................) eptic Tank (Specify Requirements)...... .. ............. )isposal Field (Specify Requirements)...................... .... ..... ............................. . ---•--•---..... --------•------•--......_....----•------.....---- .._ .. .. . ............ . ... ....... ...........................................................•---•----•-•--..._......---.---.... (Draw existing and required addition on reverse side) hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County rrdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents gnature 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 become subject to Workman's Compensation laws of California." gned........ _ ../.�.. ...... Title... ( f other than owner) FOR DEPARTMENT USE ONLY PPLICATION ACCEPTED BY...G..... .. .-•-• _...... .DATE .11 -_.� .. . ..................................... .... ............... ... ................ .. _..... IVISION OF LAND NUMBER............... _ DATE . DDITIONAL COMMENTS.. ............... .. . ......................... ......... ........................... .. ................................................................... ......... ........................................... . • . ........ .. ........................... ...... ....... ..... ........••-•---........................ ------.........----•....... -----•--••...... .................................................... .................................... nal Inspection by:....�<.. -... •-•-- . .....Date. ........ ... ..... 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 REV. 7/76 3M