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FR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- ---------------------------------------------- -- - -__ ____ S (Complete in Triplicate) Permit No_____ ____ ____ - - Date Issued -7 -_77 -------------------------------------------------- ----- This Permit Expires 1 Year From Date Issued P 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. 54 and existing Rules and Regulations: ADDRESS/LOCATION -l�_I______ ___________________ _CENSUS TRACT_________ --------------------- -- --- (16- Address / ---------------- JOB Owner's Name----- - - --------.5-� < .�---------- ------------------------------------------------- Phone-V,� Address---- ---------------1 ------ City - - Zip(� �_- ------------ city /-----p-- --------------- Contractor's Name-------- ____J. -SD7�iJ License #. ,53_ ----Phone(o_`__ L��a�------- ------------------------------Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other---------------------------------------------- Number -------------------------------------- -----Number of living units:--- -------Number of bedrooms-- .?----Garbage Grinder---------Lot Size- ----- -------------- 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 X. Adobe K Fill Material__ ______If yes, type________________________-_ (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 if public sewer is available within 200 feet,) i PACKAGE TREATMENT [ ] SEPTIC TANK ,, Siize_______J�____,K__ _�- ------------- -----------------Liquid Depth-_------ ------------------------------------- _ Capacity-/ -------ZType �-- --------Material-- -------No. Compartments '' Distance to nearest: Well-_ ---t'______________-Foundation_______ Prop. Line_------_____________. LEACHING LINEA No. of Lines________ _____________.Length of each line------- ___________Total Length ___!_6Q_ ----------------------.-- �P ,J 'D' Box--- -Type Filter Material__ _____________ Depth Filter Material_______/& _._______________________________________- t � Distance to nearest: Well____l _f ____.__Foundation__lb__*_________Property Line-----�4D_-1-0---______________-. SEEPAGE PIT [�, Depth__ t___Diameter_�3_��_______Number__________�3___________- Rock Filled Yes`k No ❑(n If Water Table Depth-------------------- ------------------------------------Rock Size- 1L2..------------------------- „ r Distance to nearest: Well--------- ------------------Foundation________e pp -+ PLine__7S'_ i`"_______ REPAIR/ADDITION (Prev. Sanitation Permit#--------------------------------------------------Date.__.__________________________________) SepticTank (Specify Requirements)------------------------- ----------------------------------------------------------------------------------- -------------------- ------- Disposal Field (Specify Requirements)-- ------------------- ------------------------------------------------------------------------------------------------------- --- ------;�1410 0 ----------------------------- ----------------------------------------------------------- ---------------- (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 certifythat 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- V - - -- --- - ---- --------------------------------- ( other than owner) FON D ARTMENT USE ONLY APPLICATION ACCEPTED BY------ - - --------------------------- DATE_�P r� ------------------------ DIVISION OF LAND NUMBER--------------------- - ------------- - DATE ------- - ----- ADDITIONALCOMMENTS------------------------------------------------------ ---------------------------------------_---------- ------------------------------------------__--------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ------------------------- --------------------------------------------------- ------ -------- --- ------------------------------------------------------------------------------------------------------------------------------ ---------------------------- -------- P Y:----- --- /I -r Final Inspection b -- - - - ----------------------- Date t 5 EH 13 24 SAN JOA IN LOCAL HEALTH DISTRICT F&s 21677 REV. 7i76 3M