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FOR OFFICE USE: FOR OFFICE USE: ............. . APPLICATION FOR SANITATION PERMIT .. .., .. . .... ....._ Permit No... .. l (Complete in Triplicate) _..' _l. ... . .............. Date -------------___—_-...................---------------- This Permit Expires 1 Year From Daft 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 Regulations; JOB ADDRESS/L TION -.� ... ------ ._.. /� .-- - ---CENSUS TRACT_,,A .-- Owner's Name. - - - Phone..=74100 =-.7. . Address------- . City- ------------------------Zip....................... ...... Contractors Name.. license # e .... ..7!�.... .Phone. o,� r Q. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other......--............ ...................... Number of living units:................Number of bedrooms,.. Garbage Grinder............Lot Size-- .�...... .......... ...... Water Supply: Public System and name..... ............ .............................. - - ------------ ....................................Private 49— Character of soil to a depth of 3 feet: Sand ❑ Silt❑ 0ay ❑ Peat❑ Sandy Loam ❑ Cloy Loam 42- Hardpan ❑ Adobe ❑ Fill Material..... ...If yes, type................................ Q (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) vs.,) NEW INSTALLATION: JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) .0 PACKAGE TREATMENT [ ] SEPTIC TANK l4010"0, size..._,.? // + ...�.._ -..._Liquid Depth. -•.............. Capacity+ i0--------.Type ./44,►..,.,,.Material e --- - ----------No. Compartments----- --------...... .......... Distance to nearest: Well.. * ¢.�..__.____._ --- Foundation __. _._ - ��---....,.... Prop. Line---- -- .----•--•--' -y 3 LEACHING LINE [r]•" No. of Lines.---2- Length of each lina....o075_Of-------..--...Total Length ................... 4# D' Box./V-.,.Type Filter Material./r/6/6�4-Depth Filter Material•---- •'. -- -•--•...............•--••-•--------•-- t Distance to nearest: We11_.��___--------- Foundation . Property Line._. . �.......... ......... SEEPAGE PIT Et}- Depth.a�� -•--Diameter..��-_`_'_______Miumber........'�__-_._._________. Rock Filled Yes � No ❑ Water Table Depth Rock 5ize.. ///,� ...------------- � r Distance to nearest: Well....11q _....... ...._.........Foundation.-- --..__-- Prop. Line..4;Z716--------------. REPAIR/ADDITION [Prev, Sanitation Permit#.................................................. Date. ............................................] Septic Tank [Specify Requirements)-------- .................. ...............................----............................................. Disposal Field (Specify Requirements) __ , .r. x ,-,.,.----------------------- - — — -- -_ _..................... .....................---......................,...,......... ......----•- - _.. ..................................................... (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that At work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Jbagwin 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 n►anner as to become subject to Wo man's Compensation laws of California." Signed........ �.........................__. .._.... -�- Owner r - By...... --- ----- ... ...................Title.- ...............---------------------d---------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - - - ---------------------- -------------- DATE i - ----- DIVISION OF LAND NUMBER_................................. .._.....---._._......._...._......-•-•-•-•-••--•----•..,..,............DATE_......._ �. ADDITIONALCOMMENTS----•--------•----------------------------... ......_._. _... _...._-------.....---._....-_-.._------_._�__..._....___ -----....._.__.. `.._..... .. .. ........................................ ---........-.......---------•---...--•-------- -----Final Inspection by:____.-_ Dote_ --EN 13 24 qiQ N LOCAL HEALTH DISTRICT F35 0677 REV. 7/76 SM f.