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FOR OFFICE USE: FOR OFFICE USE: �r APPLICATION FOR SANITATION PERMIT -V//--------------------- 77- l� Permit No,_ y/7` 7� (Complete in Triplicate) --------- - ^ Date Issued_.._.__-_________ -tom-- ------------ ---------- -- --- ---- This Permit Expires 1 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. 544,9 and existing Rules and Regulations.: JOB ADDRESS/LOCATION_,4-----,_ ------ ---------- __- �. .-t---- ---- --- ----- ------------ � CENSUS TRACT---------------------- F - ---- Owner's Name__________ ___ __ '` r� - -}} - -- ------------------------- Phone----------- ---- ------------------ Address s --- C= ty p -------- - Ci Zi Contractor's Name-.--_ _ _ _. _ -----------------------------License #-274S-jY-----Phone___'L------------------------- Installation -S �vf� __ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ r Motel ❑ Other------------ -------------------------- ----- _ Number of living units:.-___ --_Number of bedrooms..--.Garbage Grinder___.___ Lot Size--�� 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-____.______.._-----.___-------. (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 [ ] SEPTIC TANK [ ] Size-----------------------------------------------------------Liquid Depth--------------------------- Capacity_------------- ----Type-- --------------------Material--------------------------No. Compartments-----------------------------------� Distance to nearest: Well ---------- _Fec�ndet+en---------- _--------P-r-op. Line--------------------------s LEACHING LINE [ ] No. of Lines-----------------------------Length of each line_---_----------__---- ----_---Total Length ..-___--___ �-- -------------- 'D' Box-----.----._Type Filter Material--------------------Depth Filter Material-------------------------------------------------------------- - Distance to nearest: Well----------------------------Foundation----------------------------Property Line_._____--___-.-_--._--__-_-___-___1" SEEPAGE PIT [ ] Depth------ __..-----Diameter___------___---_----Number ---------------- Rock Filled Yes ❑ No ❑� WaterTable Depth---------------- --------- --- ------------------------Rock Size------------------------------------------------- Distance-to nearest: We--" _ Foundafion--------------- drop. Cine REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date-_------------------------------------------ Septic Tank (Specify Requirements)--- ------ ---- ----- --- - - -- ----------------------------------------------- 7......... Disposal Field (Specify Requirements)--------- -- - - ------ `-� •• -------- ----------------- --------- - - - `� ----- -- ------------------------------------------------------------------ - - - -- - ---------- -rd � ----------------------- -- --------------- ------- -------- ---- - --- (Draw exi mg and required addition on reverse side) Mx 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 jec , to Workn Co pensation laws of California." Signed.-. _- -- ---- -�Owner) __+......--- -----Owner•BY _______________________________________________(If other �T FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -- - - - --- ---- - ___________________DATE.__ - - ----------------------------------- -------------- - DIVISION OF LAND NUMB 'f� -DATE....__. _.....--. _ ._ ---- ADDITIONAL COMMENTS----- ----- --- ----------------------------- - __ Final Inspection by -- - -- ----------Date.---- EH 13 24 SAN JOAQUIN LOCAL HEAL T DISTRICT F&S 21677 RE /76 3M