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FOR OFFICE USE: FOR OFFICE USE: ---- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ---- --------------------------------------- Date issued.-l/—/& 77' _-___---_ ------------------------------------I-------- ------ - - 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 therAN r d. This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations. 1s�JJ�JJ' TION 00 ADDRESS/LOCACENSUS.TRACT Owner's Name !/ _-' - -----.-------------- - - - Phone Address -------------------------- "1 Cit Zi y'S Y p Contractor's Name-- ------- ----------License # Phone Installation will serve: Residence,W , 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 7-1Character of,soif:,to a depth of 3 feet: _ .Sand ❑,,Silt E]; Clay ❑ : Peat.❑ -___Sandy Loam ❑. -Clay Loam ❑ �4 Hardpan ❑ Adobe ❑ Fill Materia[------------If yes,,type------------------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 tarik'or seepage,.pit permitted if public sewer is available within 200 feet,) + PACKAGE TREATMENT [ ] "SEPTIC TANK' [Lj .`Size------ ---- :------------------------------------ __:Liquid Depth Capacity Ype - .__Material === =:No. Compartments ' ------ f Distance to nearest;.Well 1 _Foundation--------- _Prop. Line_------------------------- LEACHING _LEACHING LINENo. 6f,Lines . :____--.Length of each,lin .- , . ---y ..Total Length ,- -- ------------------------------- D' r Box Filter Material- _----- --Depth Filter Material---------------------- ---------- y ---- --- - -- Distance to nearest: Well__--------------------------Foundation------------------------------Property Line_------------- -------------- 1_..0 SEEPAGE PIT [ ] Depth----------------Diameter------------------ K NumberJ--------------- ----_--------'_ Rock Filled Yes E] No'❑SNI Water Table De th...: - = --------------- -.Rock Size------------------------------------------------- Distance'ao nearest: Well--:--------------°-------------------- -------Foundation---- -------------------Prop. Line------------------------------ REPAIR/ADDITION (Prev. Sanitation Permit�#__;_____�.___..�`=__:_._` ____________________Date____________ -------- ----- Septic Tank (Specify Requirements]__------------- --- -- ------------------ .......... Disposal Field (Specify Requireme ts]'-- -- ----- - ------------- ----------- 0 ._ .- --- - ------ ----- - -------- r ------ ---- ,--- -----.------------------------------------------ ----------------- -------------- --- ----- 1`' ' ` ]Draw'existing 'and required addition on reverse side] `� I hereby certify that I have preared 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 followingr "I certify that in the performance of'tlie work for which"this permit is issued, I shall not employ any person in such manner`as to bec me subject to Warknian's C mpensation laws of California." Signed --- `: ----- --- - - ----- - -Owvner 9 , By-,---------------- --------- --- ----- ----- --------- ---------------,.- ----'-------------- -'""1Title--- -------- ---------------- --- ------- -------- ......................... k ]If other_thah'owrier] �! . ... ... t FOR_DEPARTMENT;USE-ONLY APPLICATION ACCEPTED BY-__ !t • - DATE' ---� T--------------------- DIVISION OF LAND NUM BER - "� 5="4 © =f :---=------------------- DATE. ADDITIONAL COMMENTS------------------------------------ -------------> f"A-:1j16 ----------------------------------------- ---------------------------------------------- ------- - -------- ------------------- ------------- -------------------- , ---------------------------- -- - -------------------------- - -------------------------------------------------------- - �------`----------------------------------------------------------'-------------------- ---------------------------------- T - Datel '- ---_-_.-` . ,--. _Fin - ----------- ----- -------------" EH _._ 13 2d SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21577 REV. 7/76 3M