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FOR OFFICE USE: t,� ---•-------- PPLICATION FOR SANITATION PERMIT FOR OFFICE USE: ' -- (Complete in Triplicate) Permit Nw.,/.= ..: A P _ ----------- -- ------ This Permit Expires 1 Year From Date Issued Date i 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 o. 549 and e 'sting Rules.and Regulations: JOB ADDRESS/LOCAT ..- .c...... ............--.CENSUS TRACT..-._.... Owner's Name...(. , . ' - .....................Phone------ Address.... ....: -... City.- A. .....Zip- i Contractor's Name...... .. ,... ........License # 5,�/_....Phone-. -- Installation will serve; Residence,�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- -- ....... Number of living units:...V..........Number of bedrooms-... — Garbage Grinder. Lot Size-.�`�C�lC � ------- .. ........ i Water Supply: Public System and name__ -..Private U Character of soil to a depth of 3 feet: s Sand E] 5' ❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ Hardpan ❑ r Adobe Fill Material.. .... ....Ifes type YPe_.... ............ (Plot plan, showing size of lot, locationiof system in relation to wells, buildings, etc..must be placed on reverse side.) NEW INSTALLATION: (Na septic tank or seepage pit permitted,if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANKLiquid Depth..... .................... i I ] Size _------- -- --------------------------- Capacity------ - - ------Type -------- ....Material.-------------------- •---No. Compartments ---------- -------- --- Distance to nearest: Well............... Foundation.......... . .......... Prop. Line.................... . LEACHING LINE I 1 No. of Lines A......----------------. Length of each line.-------.----................. Total Length t 'D' Box._ ........Type Filter Material........ .... Depth Filter Material------":..-6............................ Distance fo nearest: Well.........:........ .. ..... Foundation.................... Property Line.... ......_...._ SEEPAGE PIT f l Depth------ --- -----I.Diameter---------------.„ Number-.------------------------- ---- Rock Filled Yes ❑ No ❑ Water Table Depth.--R-------------- --------- -------------------- ----Rock Size.................... . i i Distance to nearest: Well---------•-----.-- ------Foundation....:.................... Prop. Line................. REPAIR/ADDITION (Prev. Sanitation Permit#.-:.-...-_--- -"--`-'"-"" .-.:.,.--._.Date.-_.'- -. } Septic Tank (Specify Requirements).... � ..... ....-------.i.. ............. .... ... -i . Disposal Field (Specify Requirements).,/_....Z� • - _ (� -- ��c t �r? y �f-�Lf� 1 ee ------ ....... P -------------- ------ -- -- ------------ -- -- ----------- (Draw existing and required addition.-on-reverse side) I hereby certify that 1 have prepared this application and that the work will beAdone in accordance with San Joaquin County Ordinances, State Laws,. and Mules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California. f • r Signed- ....... � O_ caner BY------------------- f - - Title.-- -- (If other than owner) DEPA TMENT USE ONLY APPLICATION ACCEPTED BY-. . c.:--.. . :. --------- ----- --------------- . -----...DATE .- ... ... .._. _........ DIVISION OF LAND NUMBER. ---- # ------------------ DATE.-..... ----.... ........ ... ........ •---------•--- ADDITIONAL COMMENTS...... ----------•.............. ....... ....... t , ---------------- - -7.------------------- ------------------------------------------ - ... • :.. Fina! lnspecnan b t . y:�__ ......- --� --� ..... ..-- -------••------------------------ - - ----- - ------.-.Date... -`_5.1-- �F EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT FSS 21677 REV. 7/76 21,