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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I I �� (Camplete in Triplicate) Permit No _?7 f h •.__ •---___ ------------------------ f --------- sr�. [ t " .•. ` " Date Issued- /---'�-77 --•---------------------- ---------------- ---.-- 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: JOS ADDRESS/LOC 10'N- , -- _ ,----"-_ U T T / -- ------------------------------ -------- ------------CENS S -TRACT-------- ------ ----------------- Owner's Name_-_� _ :_ J ._. . --- - - ----- -- hone Address.--- {-ej_,�'' , ---------------- --------- ---------- � "-- City .-. . -- ---- -----zip------------------------------ en ---- ------ •------- -- 1 i Contractor sName_- �. -- _ 'License #-- -%15 _-_-Phone---------------------___ 1 �� Installation will serve: Residence f�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel-0-<---Other__.-----=--------'---------------�------=---- Num ber of living units:------- -:--_--_Number.of.bedr oms__-- --_-_ { (f -Garb ge Grinder_-_`_----+__Lot,Size---- Water Supply: Public System and name-----------& _ - _ ..- ----------- - ------Private 1 1 Character of soil to a.depth o'f 3 feet: - Sand ❑ Silt n "Clay ❑ ' Peat Lj Sandy Loam ❑ Clay Loam ❑ ! Hardpan ❑ Adobe: Fill Material__---------If yes, type---_.--_.__ ': (Plot plan, showing size of lot, location ofsystemliri relation to wells, buildings, etc�avai�lable ed on reverse side,) NEW INSTALLATION: (Nonseptic tank or' seepage pi it if public sewerithin 200 feet,) PACKAGE TREATMENTfj';] , SEPTIC TANKSize---------------_----------- --------------------------Liquid Depth--------------------- k Capacity ='= =;Type------ -- ----- --Material----:-- F No. Compartments-------------------- ------------ • I Distance to.nearest: Well"----- -----------------------------------Foundation-------------t 1 Prop. Line ` - it LEACHING LINE j'.] No. of Li_nes.-------'------€------`- ----Length of eacb_line..-=--- t-----------.Total Length ------- --------------------------- N .. I 'D' Box--;---___-.-Type Filter Material Filter Material_________ ---------__ .. . . - t Distance to nearest: Well-M1--:--- --_ -___-------Foundation----"------------------------Property Line------------------------'--____--- SEEPAGE PITx"[F] Depth----• Diameter----------------------Number-------------------__--_-_- Rock Filled Yes ❑ No l . .-.t ., Water Table Depth-- r------------ - �.. Rock Size-- --- ------------- Distance:to"nearest:Well------- {------ `----•--------Foundation.-' -'-----------------Prop. Line -------------------------- REPAIR/ADDITION (PreJSanitation Permit#,------- -------------- Septic ------ - -- Septic Tank (Specify.Requirements)--- -.__,_-_ _'" ----" - - Disposal Field(Specify Requirements).- '- s �� '�� a f ------------- ----------------------------- ----- -------- - - ' -- --------------- ----- - ---------- n } (Draw existing and required addition on reverse side) i I hereby certify that I 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 signature certifies the following: "t certify that"in the performdrice of the work for which thisermit is issued "I shall not 'employ p y an y person in such manner'as to become ect to .Wolemqns .Comperisation laws of California.". , Signed------ wn t By g,� - f" � . ---------- -----"_Title: , ------- -- --------------------------- --- -------------------- --- i othern owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPT-ED-By- -------------------- _�,�,_,_., _ � - _ - -------------------- ---_------------------ -----------------DATE"- - `'r�- DIVISION OF LAND NUMBER. ---- - ------------------ DATE_-_.---------- ----------- ----------------- ADDITIONAL -- ADDITIONAL COMMENTS------------------------------------------------------- - -------------- ------------- ------ - - -- --------------------------=------- -- - -'----------- ---"--- -=- ------ ---------------------------------- ---- ------------------ --------------- --------- --------------------------------------------- Final Inspection by.--- ----------------r � _ - - ------- _ -- ---------- ------- - _ -- -------------------------- Date"`^ ----------------- EH - - ;� 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f&5 21677 REV. 7/76 3m