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aL FOR OFFICE USE: / -%FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - --:------I----- - � (Complete in Triplicate) Permit No._77_—S3 ------------------------- 77-- Date Issued-__- --------------------- x- This Permit Expires I Year From Date Issued .f �f --- ---- 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 a d existin ules and Regulations: 4 JOS ADDRESS/LOCATION--------- 7----- 4 CENSUS TitACT. Owner's Name.----- ------ ----------------------------------------------- . 'Phone_ - Address----------------------- --- ----- ------. ----- - - - city - Zip Contractor's Name______________ --- -- ` -. � ,.----..-.--..-----License #' Y�� __'_-Phone__ -� Installation will serve: Residence X Apartment House.❑ Commercial ❑ Trailer Court%E1 Motel ❑ Other------ - -- ----------------- ----- ---------- a Number of living units;---1------------Number of bedrooms_ ------Garbage Grinder------------Lot Size--- --------------- Water Supply: Public System and name----------------- l --------------- Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay❑ Peat ❑ Sandy Loam E] Clay Loam Hardpan ❑ Adobe c14 Fill Material-------------If yes, type--------------------___-------' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed do reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-------------------------------__-- -----------------------Liquid Depth---------------------------� Capacity---------------------Type--------------------.-Material-------------------------.,.No'. Compartments---------------------- -- N Distance to nearest: Well.------------------------------------------Foundation--------------------------Prop. Line----------------------------r0 LEACHING LINE [ ] No. of Lines---------------------1-------Length of each line------------------------------Total Length._-::----_.-_ 'D'•Box------ ----Type Filter Material------------------- Depth Filter Material-------------------.--------------------------------------------� Distance to nearest: Well----------------------------Foundation-------------.--------------Property Line-----------------------------------.1~ SEEPAGE PIT [ ] Depth------- --------Diameter--------------------Number-------------------------------- Rock Filled Yes ❑ No ❑v WaterTable Depth--------------------------: ----------------------Rock Size---------------------------------------- Distance to nearest: Well_-----------------------------------------Foundation--------------------------Prop, Line--------------------------- REPAIR/ADDITION (Prev. Sanitation Perm' ---------------------- =--- --------- ----------Date --- ----- -----------------------------------) {��►7, SepticTank (Specify Requirements)------- ------------------------------- ----- - ---- ---------------------------------------------------------------- Disposal Field (Specify Requirements)-- - ----- ------ -- -- --- ----------------- _--_-- --- r = C.. `' c! �'' ----------- ---- ----- --------------------------------------------- -- - ----- (Dra existing a d required addition on reverse side) 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: "I certify that in the krFormance of the wLtion which this permit is issued, 1 shall not employ any person in such manner as to becom subje orkman' Compenlaws of California." Signed �S - f-- Owner 1 -•------------------------ ---- = « Title -- -- - --------------------------------------------------- By --- (If other than owner) 7 ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- _--�-__��- - _1---------------------DATE.----- �� ' ��-------- DIVISION OF LAND NUMBER-------------------- ------.DATE-----------------.- ADDITIONAL COMMENTS ------------------------------------------------------------------ -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------- - - ------------------------------------------------------------ ------ - -- ------------------------------------------------------------------- ----------- - ----------------------•---------------------------------- - --- -- ----- - - - - Final Inspection b __. --__-__ - Date._- - --------------------------- ------ - -- ----- - ---------- -------- -------------------------------------- - pY:-------------------- - ---- ------ - --------- ----------- EH 13 24 SAN JOAQUIN CAL HEALTH DISTRICT F&s 2167 /76 3M