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SE FOR OFFICE USE: FOR OFFICE U I APPLICATION FOR SANITATION PERMIT " -------------- �l (Complete in Triplicate) Permit No.- ------------------ l� 1 ! "� � pa � �7 ------------------------ ---- --------- Date Issued/-a _--____--_-._ _�/�__ _________________ This Permit Expires 1 Year From 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"I-------- ---------S, -�.l J` ✓ ------- -----------CENSUS TRACT------ ----------- ------------ Owner's Name------- ✓ --------Phone-------------------------------------- Address--- ------------------- ----------- --------------------------------------CitY- --- --1#✓1------------------ ziP Q`'r ..3�Q�-9iG ��p Contractors Name-_1 , -C:.--J� Un--s7ewtl-,* ----------------- ---License # __<7 e7 %Phone 537_ -P Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other------------------------ -------------- Number of living units:----!`---------Number of bedrooms_5__.---Garbage Grinder_ ---Lot Size------3A5----------------------------- Water Supply: Public System and name------------------ _ -------------- ----------- Private - ---------------------------------------------------------------------------- Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat[I Sandy Loam ❑ Clay Loam Hardpanf 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 if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ l Size-----------------------------------------------------------Liquid Depth---------------------------0 O Capacityf( -----TYPe /1� Material�L �y -No. Compartments--__ ----------- ------0 �t r Distance to nearest: Well__✓_- !_0-------------------------Foundation_._1-60, ___ -------------Prop. Li ";OF -----� LEACHING LINE [ ] No. of Lines_._ 3_-. "- _.Length 9f each line------7c-1`_____-______--Total Length.____- --Y ---- --- . ` 'D' Box_./_____Type Filter Material_-�-G-Z----------Depth Filter Maeerial ---l�--------------------- -- ------------- --A--- ------ Distanceto nearest: Well__.�_�___O�._____------Foundation- t�` 7-----------------.Property Line___��d--------------5 De th-- -- t---Diameter------------------ Number--.--------------------------- Rock Filled Yes ❑ N° 'V4No PIT { ] p Water Table Depth------------------------1.7-------- ------------------.Rock Size---------- ------------------------------------ 3 - Distance to clearest: Well--------------"----------------------------Foundation-------------------------Prop. Line---------------------- --- REPAIR/ADDITION (Prev. Sanitation Permit#________-----------------------------------------Date___.__________-----------------------------) Septic Tank (Specify Requirements)---- :. --------------------------------------------------- ----- ------------------------------ 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed- _ Owner -- ----------2Title -- -------------------------- ----------------------------------- BY -------- ------------------------ '' (If other than owner) FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY__ _______ DATE.__Z0--o2_7-77?7----------- ----- - --- ----- --- DIVISION OF LAND NUMBER._ ----------DATE--------------------- ADDITIONALCOMMENTS-------------------------------------------------------------------------- ---- ----------------------------------------------------------------------------------------------------------------------------------------- --------------- ------------------------------------------------------------------------------------------------------------------- ---------------•--------------------- ------- -------- ---------------- ------------------------------------------------------------------------- ---------- Final Inspection by: Date 1 f / fl Y- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&5 21677 REV. 7/76 3M