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�j FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------I------------------------------ 7 a (Complete in Triplicate) Permit 7X ' � sr�. Date Issued-- _________________ _4,J- gThis Permit Expires >E:.Year From Dale 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/LOCATION.-- - --.._. - ._ ___._ _ __ _ _. -----------------------------CENSUS TRACT------------------------------ Owner's Name.._-f 'X` —-------------------------- " ------------Phone--- Address--- - d ------ - ----- )--- ------------------------ --------------- ------City ..........----------------------------------Zip-------------------- --------- Contractor's Name_-- -- -- _ --- --- -- ----------- ---------------- -----'---- . License - ----Ph one Installation • will serve: ResidencAMtel Apartment House.❑ ❑ ❑ Commercial Trailer Court I ❑ Other- , ----------------------------------------'= Number of living units:__-_ _-.-----Number of.bedrooms_/,r! Garbage Grinder-.-._-- -Lot Size---- --- .-------;.-. Water Supply -Public-System and name------:----------------------- _ -_ ---------------------------------------------------Private Jl Character of soil to a depth of 3 feet:". Sand Silt `Clay ❑ `I}eat❑—"Sandy Lodrri-❑— Clay Loam Hardpan Adobe ❑ Fill Material..._. ....If yes, type------------------- - ' LP I (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,) r 1 1 ` i PACKAGE TREATMENT [ ] . SEPTIC TANK [.]' size:-- -_ : -�' -___________________ . Liquid Depth.._ ------------.--.- -D t.-Liquid _ Q-----Type------P-----------Material----- -----'_No. Compartments----_.-321_ _' Distance to(nearest: Well------ Q- ._ = Foundation-.- -------.Prop. Line---/-O----------- --� ' LEACHING LINE [.] No, of Lines ---- ---------..-.Length of each line_.--" --- .Total Length .__"_._:______ t � -------- i 'D' Box--- Filter Material---- Depth Filter Material___-_/_ - ---------------------------- . ii-- Distance•to,nearest: Well----------------------------Foundation----------_-----------------Property Line--------------------------------- 3EEPAff-PIT [ j Dept,__ _ - _ ___ iometer--✓_r -__"'Number--_ __--:. .-. Rock Filled Yes No E] F Water Table Depth----------=-------------=--- ---------------- ---------Rock-Size--- .- --------------------------- - 1 Distance to nearest. Well------------------------------------ Foundation--w------------------- Prop. Line--------------------------- REPAIR/ADDITION {Prev. Sanitation Permit#_ ___-_.----Y-:-_ -- -------------- Date--------------:---------- :-._---_-------_.__-) Septic Tank (Specify Requirements) - �---------- ------------------ ---- --------------- -------------------------------- 7 i ! Disposal Field(specify Requirements). ,,` , = - -------------- - �r--- _; 3 a --------•-----•-------------•---------------•---•--•---•---•---•--_-_.-----------------------------------------•-4--------------------•_ ----__________ _•--•------•---••---:--_----•--______________---•____ , ke ________________________________ ________.____________.______ _ _ -_------..----.---------._ - ---- ] (Draw existing and required addition"on reverse side) I hereby certify that'l 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 i signature certifies the following: ` "I certify that in the performance of the work for which,this permit is issued,_'Pshall. not employ-any-person in such manner as to become, subject to Workman's Compensation laws 'of.California._' Signed.----- ----- -- ---- ------------------------------Owner By -----= -- Title (I other than owner[ FOR DEPARTMENT USE-ONLY APPLICATION ACCEPTEDBY ---------------------------------------------------- DATE '/9 ~77 -�---- ----- -- { S DIVISION OF LAND NUMBER---------------------------------------- - --------DATE.-------- --- -:--- ADDITIONAL COMMENTS------------------- ------------------------------------------------ ----- ---:---------------------------------- ---------------------- ------ --- -------- ---------------------------=---'-------- ----- -------------------- - ----- ---------------------------------------------------------------------------------------------------- - 1 ----------------------------------------- ------ -- -- ----------- ------------------------------------------:--- , -------------------------- ---- --- - - ----- ------------------ ------------------------- ------------------------------ Final Inspection by:---- ---- ----- --- --------------=--- -'--"'-"---=--------------------------------------.._.-Date--------�0/2 7 11 EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M