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FOR OFFICE USE: r FOR OFFICE USE: ,. APPQCATION FOR SANITATION PERMIT 7f-,/77 (Complete in Triplicate) Permit o.-_________________ ---------------------- --------------------------------- �/1-1__________________________ This Permit Expires 1 Year From Date Issued Date Issued___= �_ 1 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----------- U _� 1 ___,/ ---------------------_.__CENSUS TRACT---------------_-.-------------- L� n , r X_ Owner's Name-- /'`-. �/�1 ------------- ----------------------------------------------------------------------------------Phone.- - --'�1�5-7-- Address------3573/------ --^-- - ---- -------CitY,1U7Zip ---- Contractor's Name----- Z,---&Z-445 -----------------------------------------------License #,Pen6 ___6 Phorv_0.9�J ` L . Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel F --------------- -----= It Number of living units:__I--- -------Number of bedrooms_3-----Garbage Grinder------------Lot Size___e ----------------..------------------------------- Water ___-__.___._____________ ___Water Supply: Public System and name---------------- --------------------------------- : ------------------ ------ --------------------------------------------Private 11;�( t. Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam X Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material------------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 a,if public sewer is available within 200 feet,) _ // N PACKAGE TREATMENT [ J SEPTIC TANK [ ] Size__ �a _Y_ ___ Liquid Depth---�--4' ---- Capacity/ --- o =- i` Capacityl -.__--TypepAff__64STMaterial__.____________________No. Compartments____-_�--------------------- Distance to nearest: Well -- ___.__-_. Fo-unclProp. Line___ LEACHING LINE [ ] No. of Lines y, -----------.Length of each line_____J otal Lenges._-_ - ---7 ' D' Bo ----Type Filter N %ateriliOwaDepth Filter Material,_ _-__ ___-------------------------- � Distance�ttonnearest: Well_�--------------------� Foundation � ___ f----_Property Line____ ,6EEPAIM-M [ ] Depth_ _._ Diarrasier__�_�l0___.Number____.._.�-: _. ,. Rock Filled Yes. " No ❑ Water Table Depth". --------------------------- _____.Rock Size .__-__ Distance to nearest: Wel) _____ - _-____ .. ----------Founition ._._ Prop, Line___ ____.____ REPAIR/ADDITION (Prev. Sanitation Permit#_.-:-__.-_._..______ ___________---- ______...Date--------------------------;_____.__________.__-) SepticTank (Specify Requirements)---------- ----------------------------------------------------------------------- .------------------------------------------------------------ --------- w Disposal Field(Specify Requirements)------ --=---- -- ---------------------------------------------------------------------------------------- --------------------------------------'------ ------------- --------------------------------------------------- - - ------------------> i �' a' - - (Draw existing and required addition,on reverse sidle) 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. Homeowner 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 ¢mploy any person in such manner as to become subject t man's pensation laws of California. t Signed-__- �- _-.� �__ Owner �'� ------------------------------------- By------------------- ----------- ------------ -----------------------rfitle-----.- =-------- ----- (If other than owner) FOR DEPARTMENT USE bNLY APPLICATION ACCEPTED-BY--------- _ - __t_-_ _ — -------- DIVISION OF LAND NUMBER--- -------------- = - -- _- -- -- -:r.:- TE ADDITIONALCOMMENTS„----- --------------------------------- - ----- ----- ----- '---- -- -- ----- ----- --------------------------------------------------------- --------------------------------- --------------------------------------_-----------------------------------------=-------------------..----------------------------------------------------------------- -------------------------------- - Final Inspection by - - Date. k2- �j f -- -- -------- - EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT Fas 21677 REV. 7/76.3 1 M