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.,a FOR OFFICE USE: FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ --------------------- ----- ---- ------ --------- - Permit No._77-- (Complete in Triplicate) - Date Issued.__."._'_�. ."__._� � - ------------ -- This Permit Expires 1 Year From Date Issued k Application is hereby made to the San Joaquin Local Health District for a permit to construct and,install the work herein described. F This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: a ' TRACT--------JOB ADDRESS/ ! ..... --- --- ----------- - ---- Ph n' 3 J Owner's Name.:_:__ - - Address"/X - City_ -. :Zip ��-�` 7 a nse ----------- ----------------- --- ----------- Lice #_ ii: * Phone Contractor's Name --_._ , 1 �... .g _ �otel ❑• Ot ---- --- -------------------------- t.... .` Installation-will,serve: esidence A artment House Commercial ❑ Trailer Court J I rba a Grinder.-- -""---`_Lot Size-----;- - { ."-... r E Number of.living units----------!_____Number.of bedrooms- ___ a g - ------- -------------- --Private ----------! " t Water Supply: Public System and'name------------ - Private ❑ Character of soil to a depth of 3 feet; : Sand El. Silt C1 Clay E) Peat E] Sandy Lopm C] -Clay Loam ❑ Hardpan ❑ Adobe Fill Material_..____... I#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' (I " Size-----`--------`------ ----- -----------------------------A---- Liquid Depth.-------:------ I ? Capacity-:::---! --T e.--- '------------ =---Material__:+�- ---`------I_- .-No:Compartments s 1 I ------ i Distance to nearest: Well __"..__ .--" Foundation :"" "" -----.-- Prop. Line - ."". LEACHING LINE. I'] No. of Lines --------- Length of each line�'� .,. --- t -- ` : 4otal Length. _,. ..------------------- ---------- LEACHING Box---------_..Type Filter Material_ -- ---------DeptOFilterVMaterial- ___f_ t - - _ . s r Distance to nearest: Well----------------- ___"____Foundation-�,------ ------------- Property Line "."_ a a . Rock Filled Yes ❑ No'❑ Depth -------.Diameter----------- - Number---=------ ---- -------------- SEEPAGE PIT [ ] p - . _ _- �- ..-. - . - ---- -- ---__---" ----------------- ' t Water Table Depth -------------------------------------------------------- 'R'o k Size"" -------- - --`--- Distarice to nearest: Well-- --------•------- -------- - :Foundation-- '----- --.Prop. Line { -- - -------------- Z R i REPAIR/ADDITION Preva Sanitation Permit#-- _= Date___._-.-�- --- =-- -------- -- - Tank (Specify Requirements)------ ------ ------------------------- - ----- --- !-- T -------------------------- Septic Dis -- Disposal Field {S ecif Re irements)".-- Com- � ��L�� i p P ` s ------- ----------------------- ------------------------•------------- -- ----------- - ---------------- -------------- -- ---------------------------------------------- ----------- -------------------- - l (Draw existing and required addition on reverse side) ) I hereby certify that.1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations oftheSan 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 i to become suWect to Workman's Compensation- laws of. California.'.'. ._ i Signed y - Owner rV ' Title ------- --------------- ----------- ------------------i ----- By----------------------------- - -------------------------------=------'-- --:------------ ------ (if - -(If other than owner) FOR-DEPARTMENT USE ONLY t N ACCEPTED. BY. APPLICATIO DATE." .... -�- 7---- = - DIVISION OF LAND NUMBER.-------------- ----------------------------------- ---------- DATE.".. 1 ' ADDITIONAL COMMENTS-----------=------------- -------------------------- ------------ -------------------- I ------------------s --------------- ------------------------------ --------------- ------------------- -----------I----- ------- --- ---- ----------- Date------ -- ----------------------------- --------------- ------------------------------------ Final Inspection b R " --- - p Y= - ---- Er+ 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&s 21577 REV: 7/76 3M r