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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 5� (Complete in Triplicate) Permit No----___ ________ /0-77 Date lssued_�____------ ____________ -------------- 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: JOB ADDRESS/LOCATION --��,?-_�?2'/)-----�- -� ''.1------------ -------------------------------------CENSUS TRACT----------------------------- Owner's Name yl�l r- —------ -- -------------Phone------------------------------------ Address------------------------ � C�t_2. Ci Zi _ s . ----------- ---------------- p----� ----------------- Contractor's Name___, / 8 -�--- dam_ ----- --- --------- - - --- ------ ----License # _ 1. - '---Phone-- ---------------------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other----------------- ------------------------- Number of living units:----____--_Number of bedrooms_-- *_____Garbage Grinder�Q(___Lot Size_____ � __Ile. __ --------- Water Supply: Public System and name----------- ---------------------- ----------------------------------------------------------------------------=------Private ❑(A Character of soil to a depth of 3 feet: Sand ❑ Silt Clay❑ Peat❑ - Sandy Loam ❑ Clay Loam El' Hardpan ❑ Adobe ill Material _ fyes, type-------------------------------- (Plot-plan, _______ ________(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 TANK D_. ./ ize ... -----Liquid Dep th.- - -/---Z----___-_-4 Capacity:- ._ i� e , 4.e_No. Compartments---- — ----------------- Distance to nearest: WeIL'_._____. �___________________Foundation----- L?____-________Prop. Line________________ _ LEACHING LINE [ No, of Lines_.=_ - -----.Leng ch line.____ g �_ _ ,�J -- �- --------Total Length. -�-�---------- --------- 'D' Box r _ - �/ i-Type Filter Material----------------- - Depth Filter Material ------_-__-------- Distan to r�e�rest: Well____�___f_________Foundation______ >>-_ _-______Property Line__ _____________________ . SEEPAGE PIT [l�i Depth_ _ __-_Diameter—? ---------Number__- ------------------------ R k Filled Yes ( to Water Table Depth-----------/2n 00------ --- --- ---- -----Rock Size---- ,�_lL_-- ---------------------------- Distance --------------- ---------Distance to nearest: Well_______4b_V__________________Foundation._/d---------------Prop. Line_____________________. REPAIR/ADDITION (Prev. Sanitation Permit#_________ _/_________�_._/__ „___.D' am__-_______________ --------- _____ Septic Tank (Specify Requirements) _X ----- ----------------------------------- Disposal )- -------------------------------- Dis osal Field (Specify Requirements)---- _ -_t -------_ -___-__-_-____.__----___---- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- (Draw existing and required addition on reverse side) 1 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 iof the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed-------------------- --------- - --- -------- Owner BY---------- ----------------- t 4V� ---------------------------------------- Title ------------------------------------ (If other than owner) FOR DEPARTMWT USE ONLY APPLICATION ACCEPTED K- - =' - DATE.--.- l� ------------------------ DIVISION - - DIVISIONOF LAND NUMBER .-------- ------------------------------------------------------ ----------------------------------------DATE------------------- --- ------------------------ ADDITIONALCOM NTS------------ ------------------------------------------------------------------•---------------------------------------------------------------- _________________________________________ _ __ _ __. ._____ _ _____________-___________-_____________________________-________-_____-______________________-_________-_-.____________-_____-_-_____________ Final Inspection by------- - ----- ----------------------------------------------------------------------------Date-- EH 13 24 �AN JO,AQUIN-LOCAL HEALTH DISTRICT F&s 21677 REV. 7i76 3M