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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 ( (Com lete in Triplicate) -------- - Permit No -__ P P - --'- -r'--- ''--- --------- --------------- '` -______-__---_----- This Permit Expires 1 Year From Date Issued Date Issued��_' S-` ?l 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 Ordin nc No. 549 and xisting Rules and Regulations: JOB ADDRESS/LO TION----d---?492 > 1 ----------------------------- ENSUS TRACT------------- ------------_ ---------- - ------ - If 7 Owner's Name- ' - - - ----- ---_ `,�yj -•- ----.--Phone-----_ Address-7- -- -- 0� ------------ ---- /-------------------------------- -- - City - 't ----------Zip - a Contractor's Name--------= -- -----------------------------------License #_-IL-7/ 3 1----Phone_- t .1- .�- `�6 Installation will serve: Residence ❑ Apartment House U Com erci lf❑ Trailer Court ElMotel E] Other--- __. -- Number of living units:.---------------Number of bedrooms------------Garbage Grinder-----------Lot Size---4 _ ----------.----------------- Water Supply: Public System and name------------------ --------------------------------------------------- ------------------------------------------------------------Private Wf Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe K Fill Material-------.----If yes, type-------------------------------- (Plot ----_ --.--.-----_-.(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 [ ] Size-----------------------------------------------------------Liquid Depth--_-----___--_-----_--0� Capacity---------------------Type-----------------------Material--------------------------No. Compartments---------------------------------- Distance -- -----------Distance to nearest: Well-------------------------------------------Foundation--------------------------Prop. Line----------------- LEACHING --___-_---_.`LEACHING LINE [ J No. of Lines-----------------------------Length of each line.-----------------------------Total Length.---_-_--------------------------------2 'D' Box------------Type Filter Material--------------------Depth Filter Material------------------------------------------------------.---------- Distance to nearest: Well----------------------------Foundation------- --------------------Property Line----------------------------------- SEEPAGE PIT [ ) Depth----------------Diameter-.------------------Number--------------------------------- Rock Filled Yes ❑ No LJ" WaterTable Depth--------------------------------------- -----------------Rock Size------------------------- ---------------------- Distance to nearest: Well---- ----------------.---------------------Foundation--------------------------Prop. Line---------------------_- REPAIR/ADDITION (Prev. Sanitation Permit#--_---------_------------------------_-._--____.Date------------------_---_-__----___--.-_----) Septic Tank (Specify Requirements)----- . ,.! - --------- - - Disposal Field (Specify Requirements)__ __ __ --_ __- -4mr--__---_ - - --- t ------V----------------------------------------------------------------------------------------------- ------ - - - - -- ------------- -- - - - --- --- ------ ---- - - - -- ---- -- -f------------ --------------------- (Draw existing and required addition on reverse side) I here y 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 beconife s i to WarZn's m ensation laws of California." Signed - --- ---- - - - Owner ` BY---------- - --- - �f - Title - -- ------------------------- -- (If other than o ner) 042 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------------------------------------------------------------------DATE Al-Z-177- DIVISION OF LAND NUMBER.- _.-----. -----------DATE ADDITIONALCOMMENTS-------------------------------------------------------------------------------------------------------------------------------------------------------------------. ---------------------------------------------------- ------------�SA --- -------- ------------------------------------------------------------------------- ------------------- ------------------------------------------------ --- --- ----- -- ------ --- - --------------------------------------- ----------- - -- - -- ---- Final Inspection by ---Date 3� 7-7-------------- ---- 13 24 JOAQUIN LOCAL HEALTH DISTRICT F85 21677 REV. 7/76 3M 4