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FOR OFFICE USE: ✓ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------- SSM Permit No.ZB__-_74s -- - ----------------- ----- - -- ------------- (Complete in Triplicate) -------------- ---------------------- - - ]� Date Issued__F�-_,3,L-_7� __________________-_.____________________________.__ 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 Or finance N . 549 and existing Rules and Regulations: JOB ADDRESS/LOC ON------- --1 ---- - - -- --------------------------------------------- ------CENSUS TRACT----- ------------------------ Owner's Name----- - -- ------- - - ----------�---- ------- Phone- e/ ep1 Address �� City ---Zip- - Contractor's Name- ----- - ---- ----- - ---------License ----Phone__y�o3--��.------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ - Motel ❑ Other- ____________ Number of living units:----/-------Number of bedrooms---Garbage Grinder------------Lot Size-- ----�---------------- --------- Water Supply: Public System and name-------------------- ----------------------------------------------------------------------------------------------------------Privatex._ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adob00 e Fill Material_.._-_____If yes,type----------------------------- 00 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) d NEW INSTALLATION: (No septic tank or seepage pit permitted iifpublic sewer is available within 200 feet,) ] PACKAGE TREATMENT ( ] SEPTIC TANK Siz _-. _ __.-.-Z_-4 . _-_ �� `/' - Liquid Depth e - Capacity_/40,0_�)_____-TypE�_ ' __MaterialS.�K --------- Compartments.--------- �9 r ' i Distance to nearest: Well__ U_._-_.__________________._Foundation/Q------------------Prop. Line____ /Q___________-. LEACHING LINE 1K No. of Lines----- ------------------ Length of each -----------Total Length.___/24---�._-________________ D' Box--- Type Filter Material 5!_i t)_C��-Depth Filter Material___ 4�__`r._ _._ --- -------------------------------------- -- __ i r Distance to nearest: Weli__ Off_ _____________Foundation___1-4--- ________________Property Line.._ — ____. , SEEPAGE PIT ( Depth_ _ ___Diameter._3 3___-------Number-------- _____________-- Rock Filled Yes 14/ "f ' No C3i Water Table Depth------/-Q6---------------------------------------Rock Size--- - -------------------------------- Distance to nearest: Well----l_ 7 _ ............-----------Foundation____ a_-- ----Prop. Line----- REPAIR/ADDITION (Prev. Sanitation Permit#_ -_-________________________________Date____________________________________________) SepticTank (Specify Requirements)---------------------------------------------------------------------------------------------------------------------------------------------- --------- DisposalField(Specify Requirements)---------- ----------- -------------------------------------------------------------------------------------------------------- --------------------- - ----- ----------------------------------------- -- (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 mann r as to beco ait to kmanCompensation laws of California." Signed - Owner BY----------------------------------- 1) - - 1) ------- ---------Title -- - ---- ----- - (If at than owner) FQR DEPART ENT US NLY APPLICATION ACCEPTED BY - ---------------------------------------------------DATE.---- ----- ------------- DIVISION OF LAND NUMBER_---------- ----------- -' _ ATE ----- - - - 11 ADDITIONAL COMMENTS----------------- r K�r-_f_n- f� - ©,C�rc 0�14'C -- R---��-�------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------- ----------------------------- Final Inspection b __. Date______g�� ------------------------. - - - --------- - - - --------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fss 21677 REV. 7/76 3M