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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ I' _-...... - Permit (Complete in.Triplicote) -------------------•-------------------------- 10 - Date lssued..b.- ..........-74... _. ............ 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. 549 and existing Rules and Regulations: , JOB ADDRESS/LOCATION.. �Jd/---- - CENSUS TRACT....---_-------- ----- 57 Owner's Name... ..- = Ph ne_�W : - �2 ...... ----.. .... TA — T �I . � Address----- .-:-- .---- ... City p = ; 1 Contractor's Name-------- - Phone...... ...............License #. G,�7(C.... .. � Installation will serve: Residence X ApartmentHouseC1Commercial E] Trailer Court El Motel ❑ Other--- ------ -- -- ----------------- Nu �— _. - -Garbage Grinder-----------.Lot Size...� : .......... :... Number of living units:-----/, of bedrooms-- g - Private Water Supply: Public System and name-...--- .............. - ...... .............. Character of soil to a depth of 3'-feet: Sand ❑ Silt E] Gay E] Peat El Sandy Loam C] Clay loam ❑ Hardpan ❑ Adobe Fill Material ...........If yes, type..- ....... Plot p Ian� showing g size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I ' NEW INSTALLATION: (No septic tank or seepage pit, permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK j ] Size---------------------------- :_`. ... . Liquid Depth..::_.---------_•--------- �..............��-.TYPe--•----------- Materiol--------------------------No. Compartments ---.:.:.... Capacity I .. Distance to nearest: Well.......-.......-----..........- - - ------- Foundation.......... .... ........Prop. Line...................... ..... LEACHING LINE [ ] No, of Lines....—....... •---•-•.Length of each lino:-"--------•-----------------Total Length ....------------•------------- -------- 'D' Box......... ..Type Filter Material...----- .....- ...Depth Filter Material................. -.Foundation-------------?----- Pro ert Line.............------- ---- --- . - Distance to nearest: Well-..................... -- - p y SEEPAGE PIT [ ] Depth---- =...Diameter--------------- ----Number... .---------------- --- Rock Filled Yes ❑ No❑ WaterTable Depth.---------- ------•-------- --- -------------------••---.Rack Size---- ..-- .....---. .......--•---------- Foundation.._... Prop. Line.-- Distance to nearest. Well.....:--------- ..... . k REPAIR/ADDITION (Prev. Sanitation Permit#-.-...---'•------'-----.................. .......I__Date---------=------------- ------ --------- -- -------- ) 1 Septic Tank (Specify Requirements) ;... �.. ------------------------------ -- ----- Lr Disposal fi d�(Specify Requirements]..��.A - - ......... E (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State taws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licensed agents signature certifies the following.- "I ollowing:"I 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 suble . p W rkm s Co ensat'son laws of California." k Signed------------ -- -�Q- Owner ` BY------------------------ ----- ....---....... - ------- -------------- Title--- -- - --ti-•- (If other than owner) It DEPA T T U E ONLY APPLICATION ACCEPTED BY----------- - - . ,vp sf.... .. ------- .DATE ....... . .....I .. _...- . ......... I � -----------------•---•------......DATE. -------�- - �----...---- --- ........ ..-.. I DIVISION OF LAND NUMBER...................... ------ ADDITIONAL COMMENTS--------- ------- --....•--.......... ---------------------------------------------------- ---------------- --------------------- ........ -------J_A ---------------------------------------------------- - �-,Final dnspecfion b - ---•-------- -•----•.........Date... 7 p65 21677 REV. 7/76 3M DISTRICT H'13.24 SAN JOAQUIN LOCAL HEALTH