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a FOR OFFICE USE: FOR-dIPHCE USE: APPLICATION FOR SANITATION PERMIT 77� (Complete in Triplicate) Permit No................. . . --------- ------------------ ------------------------- Date Issued......is.....4F-......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: r . - - -- - ---------CENSUS TRACT------ --- -- ------------------ JOB ADDRESS/LOCA N._/__1G_�.s. -----.�`�_.. --------- ----- ---- - Owner's Name.--- -- -- - Phone ---------- Address-- ----------- City--- ------ - -- ---------------Zip----------------------- I Contractor's Name ---------- _ a License #_ v Phone ---------- Installation will serve: Residence 2T111 Apartment House❑ , . Commercial ❑ Trailer Court Motel ❑ Other-- --------- Number of living units:------- _....Number of bedrooms-----I -Garbage Grinder.-- -.----Lot Size---- -' -- '---------._ V ---------------- Water Supply: Public System and name------------------- ---- ---- ------- --- ---------- - ------------------------------------------------------=------- Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material---------..--If yes, type.-=..------------ � f (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 i public sewer is available ilable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [Af Size_ �...x ___�1' --------------------------Liquid Depth..., /----._-- Capacity.,IAee..-------Type- -Materia---------No. Compartments--------------- ------------------ Distance to nearest: Well /vG'�-----------------Foundation__ ......Prop. Line... ------------ LEACHING LINE [e No. of Lines-----...-3--._.-.-t Length of each line--------_30�7�----------Total Length.--11--Z-5.4-l"`------._ D' Box----/-----Type Filter Material------5_ -----Depth Filter Material-------11`.............._.--_-..---------------------- - . - Distance to nearest: Well--- ----/:- a ....Foundation---_�.��..---.Property Line-.....z'" SEEPAGE PIT [ Depth.- 3 Diameter_,-----!_A4..-Number----._--- -------------------- Rack Fillet{ Yes [KNo 0 a � Water Table Depth--- ----------f � ------------------------ Rock Size 2---�`- ti - Distance to nearest: Well.. c - ---------Foundation---/k, ---_.Prop. Line... .---------- REPAIR/ADDITION --. _REPAIR/ADDITION (Prev. Sanitation Permit#-------- n------------- -----------------------Date---------------------------------------------- Septic ----------- -------Date.._--------------------.----_--------------- Septic Tank (Specify Requirements)---------------- ----- -- - ___ Disposal Field (Specify Requirements)--------------------- -7--- -------------------------------- ------ ---------------------------------------------------------------------------------------- (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 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed---------------------------- -------------`':-Owner BY -- -------------- Title.- L. . (lf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- DATE. .. DIVISION OF LAND NUMBER----------------- ---- ---------------- DATE.-------------------- ADDITIONALCOMMENTS-------------------------------- ---- -------------------------------------------------- ---- --------- ----------------------- -- ----------------------- ------------------- ------------ ------------------------------ ------------------------ --- --------- -- ---------- y------- -- - Final Inspection bY------- - � = = Date €H 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M