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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT FOR OFFICE USE: p (Complete in Triplicate) Permit No.7.7_-�7_j P This Permit Expires 1 Year From Date Issued 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 an existing Rules and Regulations: JOB ADDRESS/LOCATIO 7 J ----CENSUS TRACT_ __ ----- ____ Owner's Name--- ----Address - '� one - --- c;ry ~" Ph License / Pzip-Contractor's Namehone- -- �--- Installation will serve: Residence pA artment House Commercial Trailer Court ❑ Mote) ❑ Other- - - ------ ------ ------- -- --- ---- -- Number of living units;-----/.-____ Number of bedrooms.-A' -Garbage Grinder_G'' -Lot Size----- Water Supply: public System and name___ .--. --- -- -- - -� - - - ----- Character of soil to a depth of 3 feet: Sand [ISilt❑ Clay ❑ Peat ❑ Sandy Loam E] Clay Loam --- ------ Private'o Hardpan ❑ Adobe IXFill Materiae Z.. 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,] PACKAGE TREATMENT ] ] SEPTIC TANK1 % Uize .. - - -- ----- --Liquid Depth Capacity_ P.6�' Type e -- �- � -- t' Matarialt1�0. Compartments Distance to nearest: Well / / Foundation t --� ----- ------ LEACHING Prop. Line__-�-- -- LINE ----- ( No. of Lines ---,- Lengt # each line-- '= { C)Tota) Length. ------------ 'D' Box Typec e_--__ Depth Filter Material--..__ 4 Distant to nearest: Well .....- - _ ! �/ iter Materia Foundation Property Line. --- SEEPAGE PIT . -�� � Depth. �.__� ---.Diameter -�.�?�--- --Number..-. --- Water Table:Depth -,�- �-.---- -- - Rock Filled Yes � s� I - -` -./ - Rock Size- ' Distance to nearest: Well--. --- -- 4 --------Foundation.- L--`, r-- Prop. Line -�--� -- � REPAIR/ADDITION (Prev. Sanitation Permit#------- ---- --- -------------Date --- -- eptic Tank (Specify Requirements) .--. --_ -. _ - ---------- - _TDisposal Field (Specify Requirements)--. --_ -.- - _ _ . -- --- - --- - ----- ----------- ---- - - raw 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 f BY ------ - -Title -- (If other than owner) FOR DEPARTMENT U E ONLY APPLICATION ACCEPTED BY_ DIVISION OF LAND NUMBER _ ---- -- - : DATE.. ADDITIONAL COMMENTS- ---- DATE ------- - - - Final Inspection by; _ ,.,r - - � --- -- n _ Date __ V SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21577 REV. 7/76 3M