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FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------------- (Complete in Triplicate) Permit No.---7 - /g ---------------------------- + ------------ - d ___'__ 11 ______-_.____ This Permit Expires 1 Year From Date Issued Date Issue ___ 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: ADDRESS/LOC LOCATION- __ . -- {.� 'f�'- CENSUS TRACT--------------------------------- JOB Owner's Name____ -_ � 41-f— �.��'/'" -- -- ---- --- ---- --------------------------------------------------------------Phone------------------------------- .W_1 _ f Address----------------------------- --------- ------------------------------------ r` �C .� . City- -------- Zip-' ��-�------- Contractor's Name________ __ _e_4_11 __C- 1 '/I _______ _________ _._ ____License #-_ - Phone . . Installation will:serve: ResidenceM AparTment House � Commercial ❑ Trailer Crourt ❑ Motel ❑ Other------------------------------- -- -----Number of living units:----------------Number of bedrooms------------Garbage Grinder------------Lot Size----------------------------- _________________ Water Supply: Public System and name------------ ----- --------------------------------------------------- ---------------- --------------------Private Character of soil;to a depth'of feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardl5an ❑ Adobe ❑ Fill Material_---------If yes,type___________________.__ __-____ (Plot plan, showing size gf ao`]•, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (N;oy4eptic tank or seepage,pit permitted,if public sewer is available v�ithin 200 feet,) V PACKAGE TREATMENrf,, [ ];f SEPTIC TANK ( ]. Size----------------------------------------------------- ____Liquid Depth-______________________-_-C� Opacity------------ `� --------------------Material------------------------_No. Compartments--------------------------------- Distance torest:-Well___-. .______________________Foundation_______-__-____E_________Prop. Line-------------- -------------k LEACHING LINE? [ ] Not of,Liiies_.. '--:----.__--.-.Length of each line.------------------------------Total. Length._____.------ ------------------------ �= ox. - ---Type Filter Material-------------------Depth Filter Material-------- ----------------------------------------------------- `Qtance•to nearest: Well----------------------------Foundation---------------..-----------Peoperty Line----------------.-----------------. SEEPAGE PIT j eph----------------Diameter -.''*4umber-------------------------------- Rock Filled Yes ❑ No❑ Wa . r Table Depth----------------- ---------------------Rock Size------------- --------------------------------- -7 - -------- -------------J Distance to nearest: Wen""`---- ----`------------i_"F25�a iOn --------------------. Prop. Line___ __--__.-. ________-. REPAIR/ADDITICtN'(Prev. Sonita#ian-,Peux ##<_-_. --. -------_ _ - ------ L ,. ---------- --- - ---- -----) Septic Tank (Specify Requirements).___ A {i I _ ___-. - -- - - ---- _Disposal Field (Specify Requirements)___ ----=------ t_ - # � ------ ------ ------- - i ------- ---- --- - ---- - `'- (Drdw existing and requiret(tlddition on reverse side) I hereby certify that I have:prepared this application and that the;work will be done in accoM, once with San Joaquin County Ordinances, State Laws, apd 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 or an's Compensation laws of California." Signed. % --------�� lK Owner By------ ------------------------------------ - Title - - (If other than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- c_- -_. - - DATE s _ 5 DIVISION OF LAND NUMBER - --------- - DATE --- ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------- ------- -------------------------- - __ -----------------------. _ -- ------- ---------------------------------------- --- -- -- --- -- --- Final Inspection by:--- ---- -- --- -------- -------- ----- Date - S. S`_ 7 . EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F8s 21677 REV. 7/76 3M