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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 5� ---------------- z 77' f --------------- (Complete in Triplicate) Permit No.-___------------------ ------------------- _ -_ --._-_-__-. �"t / ,77 Date Issued_ _______ -------------- This Permit Expires t 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 _1 ' /-------------t-----------------------------------.._CENSUS TRACT-------------------------------- - Phone-------------------------------------- Owner's - - -Owner's Name------ ------- --- ------- Address --- Address------------------------ -----------------------------ZiP _ __ ,� --- - �� Contractor's Name____ -- --------------License ---- l_�- - Phone Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other--------------------- ----------------------- ��-�� Number of living units: - Number of bedrooms Garbage GrinderPc[ Lot Size ,/- , 4- ----------- Water Supply: Public System and name------------------ -------------------------------------------------------------------------------------------------------=------Private ❑(A Character of soil to a depth of 3 feet: Sand ❑ Silt,. Clay ❑ Peau❑ Sandy Loam ❑ Ctd� Loam ❑' Hardpan ❑ Adobe ill Material-_ #yes, type_______ -______ - a (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 [� ize-__ _ / '��--� ---�--1--��.....- ----Liquid Depth--.-..--- -- -----------� i Ca ac P aty==f_-` ------ ._._A.:--Type- ZG -----Mated �0 _1"4,c._-- No. Compartments---�_/----------------- Distance to dearest: Well `_____,__�__ _________________Foundation_____ U____'___-_-_--Prop. Line__/____________ _ LEACHING LINE [X No. of Lines__ --- ------Leng ch line-----{/______-_---.Total Length ___�_�________________ D' Box Type ____---__ Depth Filter Material____ /� _ __�"__T a Filter Material________ _ .______________.____.___ Distanto geprest: Well____�„��__ _______Foundation____ l _______Property Line___ / SEEPAGE PIT ( Depth__ ___'S_-_!__Diameter-_ 3__.------Number---- ------------------------ Rk Filled Yes ® 0 Water Table Depth-----------/Q f!-----------------------------------Rock Size , .l--- ---------------------------- Distance ---_-_------ ----------Distance to nearest:Well---------- -- _V______._._..------Foundation_lQ__!-----------Prop. Line___,_5____. -------------- REPAIR/ADDITION (Prev. Sanitation Permit#--. ____.____ Dam________. _______ ____________) Septic Tank (Specify Requirements) -------- /f - - Disposal Field (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, 1 shall not employ any person in such manner as to become subject to Workryiian's�f Compensation laws of California." Signed------------------------ ------ ---- --- ----------------------------Owner BY------ -------------------- /"f 1 - - - ------Title.�� ,/ G ' ` 1 (If other than owner) FOR DEPART T USE ONLY APPLICATION ACCEPTED K- = u -----------------------------DATE.- ---- --A ----------------------- DIVISION OF LAND NUMBER. - ----------------------------------------- DATE----- -------------------- -------- ADDITIONALCOM NTS------------------------------------ -------------------------------------------------------------------------------------------------------- ---------- ----------- �'- --f1 ---------- ------------------------------------------- ---------------------------------------- - --- - --- ------ - --------------------------------------------------------------------------------------------------------------------------------------------- Final Inspection by:------ - ----- ------------------------------------------------------- ----------------Date.. EH 13 24 N JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7176 3M